Provider Demographics
NPI:1679973010
Name:WISE, PAMELA LAWSON
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:LAWSON
Last Name:WISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1460 HOLIDAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-5537
Mailing Address - Country:US
Mailing Address - Phone:704-941-4592
Mailing Address - Fax:
Practice Address - Street 1:1460 HOLIDAY BLVD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5537
Practice Address - Country:US
Practice Address - Phone:049-414-5927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist