Provider Demographics
NPI:1770134959
Name:WINGO, PAMELA (LPN)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:WINGO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4166 LINDELL BLVD STE 1B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-2923
Mailing Address - Country:US
Mailing Address - Phone:314-484-7758
Mailing Address - Fax:
Practice Address - Street 1:6110 HOWDERSHELL RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1170
Practice Address - Country:US
Practice Address - Phone:314-942-9499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
MO2009031393164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500075300Medicaid