Provider Demographics
NPI:1861632457
Name:CAMPBELL, PAMELA PELLETIER (RD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:PELLETIER
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:MARY
Other - Last Name:PELLETIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2924 BROOK RD
Mailing Address - Street 2:CHILDREN'S HOSPITAL CREDENTIALING DEPT
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-1215
Mailing Address - Country:US
Mailing Address - Phone:804-321-7474
Mailing Address - Fax:804-228-5210
Practice Address - Street 1:2924 BROOK RD
Practice Address - Street 2:CHILDREN'S HOSPITAL CREDENTIALING DEPT
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-1215
Practice Address - Country:US
Practice Address - Phone:804-321-7474
Practice Address - Fax:804-228-5210
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA922286133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid