Provider Demographics
NPI:1770638801
Name:DETRICK, PAMELA L (MHNP)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:DETRICK
Suffix:
Gender:F
Credentials:MHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7005 MIRA LOMA LN
Mailing Address - Street 2:STE 101
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1411
Mailing Address - Country:US
Mailing Address - Phone:512-470-5600
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1558782363LP0808X
NVAPRN000580363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308485000Medicaid
FLY8586OtherBLUE CROSS BLUE SHIELD
FL308485000Medicaid