1407858004 NPI number — MRS. JUDY R MACNICHOLS P.A.-C

Table of content: MRS. JUDY R MACNICHOLS P.A.-C (NPI 1407858004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407858004 NPI number — MRS. JUDY R MACNICHOLS P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACNICHOLS
Provider First Name:
JUDY
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MACNICHOLS
Provider Other First Name:
JUDITH
Provider Other Middle Name:
RUBIELA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407858004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 N STONE ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
DELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32720-0919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-943-7100
Provider Business Mailing Address Fax Number:
386-943-8909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1070 N. STONE STREET
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-943-7100
Provider Business Practice Location Address Fax Number:
386-738-8909
Provider Enumeration Date:
08/12/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA3264 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA3264 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 290967700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".