Healthcare Provider Details

I. General information

NPI: 1720009632
Provider Name (Legal Business Name): PAMELA LYNN FAILLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date: 04/07/2010
Reactivation Date: 06/23/2010

III. Provider practice location address

525 E 15TH ST
PANAMA CITY FL
32405-5400
US

IV. Provider business mailing address

525 E 15TH ST
PANAMA CITY FL
32405-5400
US

V. Phone/Fax

Practice location:
  • Phone: 850-522-4485
  • Fax: 850-522-4484
Mailing address:
  • Phone: 850-522-4485
  • Fax: 850-522-4484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN9488802
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number136994
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: