Provider Demographics
NPI:1740484476
Name:CORK, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CORK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12625 HESPERIA ROAD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392
Mailing Address - Country:US
Mailing Address - Phone:760-955-1777
Mailing Address - Fax:760-955-2356
Practice Address - Street 1:12625 HESPERIA ROAD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392
Practice Address - Country:US
Practice Address - Phone:760-955-1777
Practice Address - Fax:760-955-2356
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA492619163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health