Provider Demographics
NPI:1154678605
Name:PRUYN, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:PRUYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SHORE RD
Mailing Address - Street 2:APT 2H
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-5301
Mailing Address - Country:US
Mailing Address - Phone:516-432-0563
Mailing Address - Fax:
Practice Address - Street 1:420 SHORE RD
Practice Address - Street 2:APT 2H
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-5301
Practice Address - Country:US
Practice Address - Phone:516-432-0563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist