Provider Demographics
NPI:1811332893
Name:MOORHEAD, PAMELA JANE (LPN)
Entity type:Individual
Prefix:MISS
First Name:PAMELA
Middle Name:JANE
Last Name:MOORHEAD
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 1:12266 LAPPLEY AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8453
Mailing Address - Country:US
Mailing Address - Phone:616-550-6257
Mailing Address - Fax:
Practice Address - Street 1:12266 LAPPLEY AVE NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-8453
Practice Address - Country:US
Practice Address - Phone:616-550-6257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703057710164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703057710OtherNURSING LICENSING