Healthcare Provider Details

I. General information

NPI: 1376962670
Provider Name (Legal Business Name): PAMELA DERAMUS HEARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5380 SOMERLANE TRL
COLLEGE PARK GA
30349-2040
US

IV. Provider business mailing address

5380 SOMERLANE TRL
COLLEGE PARK GA
30349-2040
US

V. Phone/Fax

Practice location:
  • Phone: 678-362-7862
  • Fax:
Mailing address:
  • Phone: 678-362-7862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number2014 NONPS-0077
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: