Provider Demographics
NPI:1346524303
Name:BREAZEALE, PAMELA ROSS (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ROSS
Last Name:BREAZEALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CUMBERLAND GAP
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2416
Mailing Address - Country:US
Mailing Address - Phone:361-676-1678
Mailing Address - Fax:
Practice Address - Street 1:117 CUMBERLAND GAP
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2416
Practice Address - Country:US
Practice Address - Phone:361-676-1678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX693121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily