Provider Demographics
NPI:1326318205
Name:HERVEY, PAMELA ANN
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:ANN
Last Name:HERVEY
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 1:475 MCLIN CIR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073-7939
Mailing Address - Country:US
Mailing Address - Phone:601-845-6651
Mailing Address - Fax:601-845-0230
Practice Address - Street 1:475 MCLIN CIR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-7939
Practice Address - Country:US
Practice Address - Phone:601-845-6651
Practice Address - Fax:601-845-0230
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04129817171M00000X
MS08700721171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08700721Medicaid
MS04129817Medicaid