Provider Demographics
NPI:1578811097
Name:RICHARDSON, PAMELA BROUGH (APRN, FNP-C, ENP-C)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:BROUGH
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:APRN, FNP-C, ENP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 LUCAS DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89701-5600
Mailing Address - Country:US
Mailing Address - Phone:432-294-1698
Mailing Address - Fax:
Practice Address - Street 1:890 MILL ST STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1436
Practice Address - Country:US
Practice Address - Phone:775-442-5872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX593564363LF0000X
NM61962363LF0000X
NV828304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
12450092OtherCAQH PROVIDER ID
12450092OtherCAQH PROVIDER ID