Provider Demographics
NPI:1720009632
Name:FAILLE, PAMELA LYNN (APRN)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:LYNN
Last Name:FAILLE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-5400
Mailing Address - Country:US
Mailing Address - Phone:850-522-4485
Mailing Address - Fax:850-522-4484
Practice Address - Street 1:525 E 15TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5400
Practice Address - Country:US
Practice Address - Phone:850-522-4485
Practice Address - Fax:850-522-4484
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2018-12-13
Deactivation Date:2010-04-07
Deactivation Code:
Reactivation Date:2010-06-23
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9488802363LP0808X
MO136994364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101360100Medicaid