Provider Demographics
NPI:1710105416
Name:CORRELL, PAMELA EDMONDSON (LDO)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:EDMONDSON
Last Name:CORRELL
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 BRADLEY GIN RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-7303
Mailing Address - Country:US
Mailing Address - Phone:470-364-4824
Mailing Address - Fax:
Practice Address - Street 1:2801 BRADLEY GIN RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30656-7303
Practice Address - Country:US
Practice Address - Phone:470-364-4824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO001119156FX1800X
GA1119156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5946010001Medicare NSC