Provider Demographics
NPI:1376743674
Name:WENGER, PAMELA GIBBS (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:GIBBS
Last Name:WENGER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:LYNN
Other - Last Name:GIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W A J HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:1596 HIGHWAY 33 SOUTH
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825
Practice Address - Country:US
Practice Address - Phone:423-626-2965
Practice Address - Fax:423-626-2968
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1039079163WP0809X
TNAPN12802363LP0808X
TNRN43930363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
0354813Medicare PIN
0295617Medicare PIN