Provider Demographics
NPI:1598021321
Name:WALSH, PAMELA LYNN (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LYNN
Last Name:WALSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 WOODGROVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-1584
Mailing Address - Country:US
Mailing Address - Phone:636-262-5826
Mailing Address - Fax:
Practice Address - Street 1:2133 WELSH DR
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-4875
Practice Address - Country:US
Practice Address - Phone:636-262-5826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113048363LA2200X
IL209012610363LA2200X
FL9338452363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health