Basic Information
Provider Information | |||||||||
NPI: | 1164690236 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HIMSTEDT | ||||||||
FirstName: | PAMELA | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1417 N MOUNT AUBURN RD STE A | ||||||||
Address2: |   | ||||||||
City: | CAPE GIRARDEAU | ||||||||
State: | MO | ||||||||
PostalCode: | 637012171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5738032941 | ||||||||
FaxNumber: | 8138919066 | ||||||||
Practice Location | |||||||||
Address1: | 1417 N MOUNT AUBURN RD STE A | ||||||||
Address2: |   | ||||||||
City: | CAPE GIRARDEAU | ||||||||
State: | MO | ||||||||
PostalCode: | 637012171 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5738032941 | ||||||||
FaxNumber: | 8138919066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2008 | ||||||||
LastUpdateDate: | 12/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 099824 | MO | N |   | Nursing Service Providers | Registered Nurse | Diabetes Educator | 363LF0000X | 099824 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 425114907 | 05 | MO |   | MEDICAID | P00607758 | 01 | MO | RR MCR | OTHER |