Provider Demographics
NPI:1568558534
Name:HAGWOOD, PAMELA JOANNE (MSN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JOANNE
Last Name:HAGWOOD
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:JOANNE
Other - Last Name:STUCHLAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:2912 SPRINGBORO W
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1674
Mailing Address - Country:US
Mailing Address - Phone:937-439-7411
Mailing Address - Fax:937-433-8030
Practice Address - Street 1:2912 SPRINGBORO W
Practice Address - Street 2:SUITE 201
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-1674
Practice Address - Country:US
Practice Address - Phone:937-439-7411
Practice Address - Fax:937-439-8030
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN162016363L00000X
OHCOA 00971 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2067598Medicaid
OHNP01603Medicare PIN
OH2067598Medicaid
S63631Medicare UPIN
OHNP01604Medicare PIN