Healthcare Provider Details

I. General information

NPI: 1740484476
Provider Name (Legal Business Name): PAMELA CORK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HESPERIA ROAD
VICTORVILLE CA
92392
US

IV. Provider business mailing address

12625 HESPERIA ROAD
VICTORVILLE CA
92392
US

V. Phone/Fax

Practice location:
  • Phone: 760-955-1777
  • Fax: 760-955-2356
Mailing address:
  • Phone: 760-955-1777
  • Fax: 760-955-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number492619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: