Provider Demographics
NPI:1467684415
Name:MICKEY, PAMELA
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:MICKEY
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 1:7127 LATOUR CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-3958
Mailing Address - Country:US
Mailing Address - Phone:703-768-1928
Mailing Address - Fax:
Practice Address - Street 1:7127 LATOUR CT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-3958
Practice Address - Country:US
Practice Address - Phone:703-768-1928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602006225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2306602006OtherSTATE OF VIRGINIA