Basic Information
| Provider Information | |||||||||
| NPI: | 1801380852 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLLENBERG | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | DAWN KUBAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1826 LANDING DR APT G | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327716795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144396888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 W BROADWAY ST STE 214 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327659262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2018 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-16-23587 | OH | Y |
No ID Information.