Healthcare Provider Details

I. General information

NPI: 1770134959
Provider Name (Legal Business Name): PAMELA WINGO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6110 HOWDERSHELL RD
HAZELWOOD MO
63042-1170
US

IV. Provider business mailing address

4166 LINDELL BLVD STE 1B
SAINT LOUIS MO
63108-2923
US

V. Phone/Fax

Practice location:
  • Phone: 314-942-9499
  • Fax:
Mailing address:
  • Phone: 314-484-7758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2009031393
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: