Provider Demographics
NPI:1255837001
Name:FUQUA, PAMELA DENISE (APN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DENISE
Last Name:FUQUA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 SANBYRN DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6590
Mailing Address - Country:US
Mailing Address - Phone:901-737-8068
Mailing Address - Fax:
Practice Address - Street 1:1227 SANBYRN DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6590
Practice Address - Country:US
Practice Address - Phone:901-737-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23935363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2395Medicaid