Provider Demographics
NPI:1447394184
Name:GARDNER-DAVIS, PAMELA JUNE (CNS)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JUNE
Last Name:GARDNER-DAVIS
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10299 WOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-4419
Mailing Address - Country:US
Mailing Address - Phone:804-727-8500
Mailing Address - Fax:804-727-8580
Practice Address - Street 1:4825 S LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-2713
Practice Address - Country:US
Practice Address - Phone:804-222-2607
Practice Address - Fax:804-236-9118
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001096960163WP0808X
VA0015000486364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA162856OtherANTHEM
VA007252H36Medicare PIN