Provider Demographics
NPI:1154453520
Name:CHEVILLET, PAMELA (LAT,ATC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CHEVILLET
Suffix:
Gender:F
Credentials:LAT,ATC
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:RUSCHAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT,ATC
Mailing Address - Street 1:455 TAMARACK LN
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-9134
Mailing Address - Country:US
Mailing Address - Phone:317-774-9784
Mailing Address - Fax:
Practice Address - Street 1:4700 W 10TH ST
Practice Address - Street 2:MAIL STOP M-17
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-3277
Practice Address - Country:US
Practice Address - Phone:317-242-5014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000875A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer