Healthcare Provider Details

I. General information

NPI: 1508147950
Provider Name (Legal Business Name): PAMELA JANE RATHBURN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 SAMUELS PATH
MILLER PLACE NY
11764-1921
US

IV. Provider business mailing address

405 LOCUST AVE
OAKDALE NY
11769-1651
US

V. Phone/Fax

Practice location:
  • Phone: 631-721-8872
  • Fax:
Mailing address:
  • Phone: 631-868-1244
  • Fax: 631-567-1648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberF401659-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberF360369-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: