Provider Demographics
NPI:1881459196
Name:BYRNE, PAMELA A
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:BYRNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:A
Other - Last Name:BERTELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 410823
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-0823
Mailing Address - Country:US
Mailing Address - Phone:314-432-5144
Mailing Address - Fax:314-432-2400
Practice Address - Street 1:11477 OLDE CABIN RD STE 102
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7137
Practice Address - Country:US
Practice Address - Phone:314-432-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023049469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty