Provider Demographics
NPI:1760512701
Name:WARD, PAMELA T
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:T
Last Name:WARD
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 1:2542 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:BLADENBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28320-7736
Mailing Address - Country:US
Mailing Address - Phone:910-866-4497
Mailing Address - Fax:910-863-4031
Practice Address - Street 1:7288 HIGHWAY 211 WEST
Practice Address - Street 2:
Practice Address - City:BLADENBORO
Practice Address - State:NC
Practice Address - Zip Code:28320
Practice Address - Country:US
Practice Address - Phone:910-863-4031
Practice Address - Fax:910-863-4031
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL009017311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803504Medicaid