Provider Demographics
NPI:1770247066
Name:DALLAS, PAMELA NICOLE
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:NICOLE
Last Name:DALLAS
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 1:3462 ASHFORD LOOP
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3674
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3462 ASHFORD LOOP
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-3674
Practice Address - Country:US
Practice Address - Phone:770-364-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-24
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242295163WM0102X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn