Provider Demographics
NPI:1841806551
Name:SMITH, PAMELA LOUISE (PHD, FNP, RN)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD, FNP, RN
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:LOUISE
Other - Last Name:EVANS-SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, FNP, RN
Mailing Address - Street 1:1210 DANFORTH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6234
Mailing Address - Country:US
Mailing Address - Phone:573-864-5098
Mailing Address - Fax:
Practice Address - Street 1:1605 E BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8023
Practice Address - Country:US
Practice Address - Phone:573-815-8242
Practice Address - Fax:573-815-8245
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO120866363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty