Provider Demographics
NPI:1558345553
Name:MURILLO, PAMELA SUE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:SUE
Last Name:MURILLO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:SUE
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:9509 LISSARA CAMP CT
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-9831
Mailing Address - Country:US
Mailing Address - Phone:336-408-9776
Mailing Address - Fax:
Practice Address - Street 1:145 KIMEL PARK DR
Practice Address - Street 2:SUITE 120
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6984
Practice Address - Country:US
Practice Address - Phone:336-768-3212
Practice Address - Fax:336-768-9019
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC139043367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051022Medicaid
NC2618227CMedicare ID - Type Unspecified
NC8051022Medicaid