Provider Demographics
NPI:1356417810
Name:WHITLOCK, PAMELA J (FNP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:WHITLOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 DONIPHAN DR
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-9120
Mailing Address - Country:US
Mailing Address - Phone:417-451-9450
Mailing Address - Fax:417-451-8903
Practice Address - Street 1:4016 MAIN ST
Practice Address - Street 2:
Practice Address - City:CASSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65625-9753
Practice Address - Country:US
Practice Address - Phone:417-847-0057
Practice Address - Fax:417-847-0079
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO144642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425785011Medicaid
MO000082875Medicare ID - Type Unspecified
MO425785011Medicaid