Provider Demographics
NPI:1710046966
Name:WARMERDAM, PAMELA SUE (MS RD CDE CPT)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:SUE
Last Name:WARMERDAM
Suffix:
Gender:F
Credentials:MS RD CDE CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 W EATON AVE
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3420
Mailing Address - Country:US
Mailing Address - Phone:209-832-3432
Mailing Address - Fax:209-839-6742
Practice Address - Street 1:471 W EATON AVE
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3420
Practice Address - Country:US
Practice Address - Phone:209-832-3432
Practice Address - Fax:209-839-6742
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHR703135133V00000X
CA09910714163WA0400X
CA003321163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
R703135OtherAMERICAN DIETETIC ASSOC