Provider Demographics
NPI:1629283296
Name:WALL, PAMELA J (LMT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:WALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ELDON
Mailing Address - State:MO
Mailing Address - Zip Code:65026-1834
Mailing Address - Country:US
Mailing Address - Phone:573-392-4181
Mailing Address - Fax:
Practice Address - Street 1:18 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1834
Practice Address - Country:US
Practice Address - Phone:573-392-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004007483225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist