Provider Demographics
NPI:1205172970
Name:DALE, PAMELA SUE (APRN)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:SUE
Last Name:DALE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:CAMPTON
Mailing Address - State:KY
Mailing Address - Zip Code:41301-0099
Mailing Address - Country:US
Mailing Address - Phone:606-668-9076
Mailing Address - Fax:606-668-7488
Practice Address - Street 1:31 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:CAMPTON
Practice Address - State:KY
Practice Address - Zip Code:41301-9750
Practice Address - Country:US
Practice Address - Phone:606-668-9076
Practice Address - Fax:606-668-6820
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007761363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100362470Medicaid
KYK128791Medicare PIN