Healthcare Provider Details

I. General information

NPI: 1649204140
Provider Name (Legal Business Name): PAMELA MCMILLIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 NOTCHWOOD CT
LAKE WYLIE SC
29710-6067
US

IV. Provider business mailing address

1914 NOTCHWOOD CT
LAKE WYLIE SC
29710-6067
US

V. Phone/Fax

Practice location:
  • Phone: 704-718-5139
  • Fax:
Mailing address:
  • Phone: 704-718-5139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number41130
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: