Provider Demographics
NPI:1730716648
Name:GREEN, PAMELA KELLAM
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:KELLAM
Last Name:GREEN
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 1:4575 ST. JOHNS AVENUE
Mailing Address - Street 2:SUITE # 4
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210
Mailing Address - Country:US
Mailing Address - Phone:904-710-9662
Mailing Address - Fax:904-586-2473
Practice Address - Street 1:6986 JACK HORNER LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-3620
Practice Address - Country:US
Practice Address - Phone:904-710-9662
Practice Address - Fax:904-586-2473
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL688784896251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health