Provider Demographics
NPI:1902517535
Name:HIGGINBOTTOM, PAMELA C
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:C
Last Name:HIGGINBOTTOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6645 MAYFAIR CV
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1655
Mailing Address - Country:US
Mailing Address - Phone:662-519-3065
Mailing Address - Fax:
Practice Address - Street 1:6645 MAYFAIR CV
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1655
Practice Address - Country:US
Practice Address - Phone:662-519-3065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3747A0650X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider