1285806109 NPI number — JUDY STUCK APRN

Table of content: JUDY STUCK APRN (NPI 1285806109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285806109 NPI number — JUDY STUCK APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STUCK
Provider First Name:
JUDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285806109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-7306
Provider Business Mailing Address Fax Number:
803-296-7330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 LAUREL STREET
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29220-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-376-5982
Provider Business Practice Location Address Fax Number:
803-376-5982
Provider Enumeration Date:
04/01/2008

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: 363LA2200X , with the licence number:  APN275 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP1415 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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