Provider Demographics
NPI:1649742842
Name:ROYSTON, PAMELA VANTRICE (MO HEALTH NET PROVID)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:VANTRICE
Last Name:ROYSTON
Suffix:
Gender:F
Credentials:MO HEALTH NET PROVID
Other - Prefix:MISS
Other - First Name:PAMELA
Other - Middle Name:VANTRICE
Other - Last Name:GREER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HCBS PROVIDER SINCE
Mailing Address - Street 1:11581 W FLORISSANT AVE
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6740
Mailing Address - Country:US
Mailing Address - Phone:314-664-5155
Mailing Address - Fax:866-255-9006
Practice Address - Street 1:11581 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6740
Practice Address - Country:US
Practice Address - Phone:314-664-5155
Practice Address - Fax:866-255-9006
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-28
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care