Provider Demographics
NPI:1164129052
Name:BECKETT, PAMELA SUE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:BECKETT
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 1:200 S TUTTLE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-1556
Mailing Address - Country:US
Mailing Address - Phone:937-325-2816
Mailing Address - Fax:937-325-2818
Practice Address - Street 1:200 S TUTTLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-1556
Practice Address - Country:US
Practice Address - Phone:937-325-2816
Practice Address - Fax:937-325-2818
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.010056-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician