Provider Demographics
NPI:1295873065
Name:DERAITA, PAMELA ANN
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:ANN
Last Name:DERAITA
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:PO BOX 2745
Mailing Address - Street 2:97928 SHOPPING CENTER AVENUE
Mailing Address - City:HARBOR
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0326
Mailing Address - Country:US
Mailing Address - Phone:541-469-4030
Mailing Address - Fax:541-412-0670
Practice Address - Street 1:97928 SHOPPING CENTER AVE
Practice Address - Street 2:
Practice Address - City:HARBOR
Practice Address - State:OR
Practice Address - Zip Code:97415-9412
Practice Address - Country:US
Practice Address - Phone:541-469-4030
Practice Address - Fax:541-412-0670
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORHASP248590237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist