Healthcare Provider Details

I. General information

NPI: 1104854694
Provider Name (Legal Business Name): PAMELA LUSK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 3RD ST # MC2104 NP HEALTHCARE- DOWNTOWN PHOENIX CAMPUS
PHOENIX AZ
85004-2135
US

IV. Provider business mailing address

718 SOLANO DR
PRESCOTT AZ
86301-1520
US

V. Phone/Fax

Practice location:
  • Phone: 602-496-0721
  • Fax: 602-496-0675
Mailing address:
  • Phone: 928-830-7530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN054820
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP1313
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: