Provider Demographics
NPI:1740595271
Name:PAM RILLSTONE, PHD, CNS, BC, CT, PLLC
Entity Type:Organization
Organization Name:PAM RILLSTONE, PHD, CNS, BC, CT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RILLSTONE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, ARNP, CNS
Authorized Official - Phone:904-610-2761
Mailing Address - Street 1:13801 VICTORIA LAKES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-4898
Mailing Address - Country:US
Mailing Address - Phone:904-610-2761
Mailing Address - Fax:
Practice Address - Street 1:6817 SOUTHPOINT PKWY
Practice Address - Street 2:STE 304
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6282
Practice Address - Country:US
Practice Address - Phone:904-296-3113
Practice Address - Fax:904-296-3144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1247222364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty