Healthcare Provider Details

I. General information

NPI: 1720977754
Provider Name (Legal Business Name): PAMELA ROUSH
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 MORNING DOVE LN
CROSS LANES WV
25313-1111
US

IV. Provider business mailing address

5412 MORNING DOVE LN
CROSS LANES WV
25313-1111
US

V. Phone/Fax

Practice location:
  • Phone: 704-942-5312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: