Provider Demographics
NPI:1255896171
Name:GOTTBERG, PAMELA LYNN
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:LYNN
Last Name:GOTTBERG
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 1:801 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-7865
Mailing Address - Country:US
Mailing Address - Phone:402-332-3341
Mailing Address - Fax:
Practice Address - Street 1:801 SOUTH ST
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-7865
Practice Address - Country:US
Practice Address - Phone:402-332-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE41307163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool