Provider Demographics
NPI:1558583450
Name:PACE, SALLYE A
Entity Type:Individual
Prefix:MS
First Name:SALLYE
Middle Name:A
Last Name:PACE
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:P.O. BOX 515
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504
Mailing Address - Country:US
Mailing Address - Phone:304-736-6126
Mailing Address - Fax:304-736-1531
Practice Address - Street 1:2900 FIRST AVENUE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702
Practice Address - Country:US
Practice Address - Phone:304-736-6126
Practice Address - Fax:304-736-1531
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3810008043174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810008043Medicaid
WV3810008043Medicaid
WV8239721Medicare PIN