Healthcare Provider Details

I. General information

NPI: 1295737120
Provider Name (Legal Business Name): PAMELA J CONCANNON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 SOUTHERN BLVD SUITE 1
BOARDMAN OH
44512-6085
US

IV. Provider business mailing address

PO BOX 92423
CLEVELAND OH
44193-0003
US

V. Phone/Fax

Practice location:
  • Phone: 330-629-2677
  • Fax:
Mailing address:
  • Phone: 330-629-2677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN217239
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: