Provider Demographics
NPI:1710101167
Name:MARSTON, PAMELA SUE (LPN CADC DUI QHEC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:MARSTON
Suffix:
Gender:F
Credentials:LPN CADC DUI QHEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171
Mailing Address - Street 2:
Mailing Address - City:OQUAWKA
Mailing Address - State:IL
Mailing Address - Zip Code:61469-0171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 E EUCLID AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1247
Practice Address - Country:US
Practice Address - Phone:309-734-9461
Practice Address - Fax:309-734-3909
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YA0400X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILQHEICOther0137
IL23985OtherCADC