Provider Demographics
NPI:1275872491
Name:GLISON, PAMELA D
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:GLISON
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:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:FL
Mailing Address - Zip Code:32042-0071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11172 SW 85 AVENUE
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:FL
Practice Address - Zip Code:32044
Practice Address - Country:US
Practice Address - Phone:904-964-9182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1843732163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse