Provider Demographics
NPI:1518119502
Name:BAKER, PAMELA SUE (RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:SUE
Last Name:BAKER
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7322
Mailing Address - Country:US
Mailing Address - Phone:386-424-5263
Mailing Address - Fax:386-424-5184
Practice Address - Street 1:401 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7322
Practice Address - Country:US
Practice Address - Phone:386-424-5263
Practice Address - Fax:386-424-5184
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3453133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered