1184905200 NPI number — MRS. PAMELA DIANE HOLLAND IBCLC

Table of content: MRS. PAMELA DIANE HOLLAND IBCLC (NPI 1184905200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184905200 NPI number — MRS. PAMELA DIANE HOLLAND IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLAND
Provider First Name:
PAMELA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
IBCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184905200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 ROYAL LN
Provider Second Line Business Mailing Address:
NONE
Provider Business Mailing Address City Name:
POOLER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31322-3958
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-306-4619
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 ROYAL LN
Provider Second Line Business Practice Location Address:
NONE
Provider Business Practice Location Address City Name:
POOLER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31322-3958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-306-4619
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174N00000X , with the licence number:  19411880 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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