Healthcare Provider Details

I. General information

NPI: 1841597754
Provider Name (Legal Business Name): MISS PAMELA ALEXANDRIA CONNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2011
Last Update Date: 02/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10909 PORTLAND AVE E SUITE F
TACOMA WA
98445-5252
US

IV. Provider business mailing address

11106 10TH AVENUE CT E APT. C-107
TACOMA WA
98445-7090
US

V. Phone/Fax

Practice location:
  • Phone: 253-970-0433
  • Fax:
Mailing address:
  • Phone: 253-495-0580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberMA 00023814
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: