Provider Demographics
NPI:1902952914
Name:MARSHALL, PAMELA MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:MARIE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WIND HAVEN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8010
Mailing Address - Country:US
Mailing Address - Phone:859-619-3984
Mailing Address - Fax:859-224-4675
Practice Address - Street 1:109 WIND HAVEN DR STE 100
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-8010
Practice Address - Country:US
Practice Address - Phone:859-619-3984
Practice Address - Fax:859-224-4675
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY135225225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK041170OtherMEDICARE TIN
KY7100205670Medicaid