1356891220 NPI number — JUDITH LAUREN MARDER AGACNP, FNP-BC

Table of content: JUDITH LAUREN MARDER AGACNP, FNP-BC (NPI 1356891220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356891220 NPI number — JUDITH LAUREN MARDER AGACNP, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARDER
Provider First Name:
JUDITH
Provider Middle Name:
LAUREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP, FNP-BC
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:
1356891220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742616
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:
30374-2616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-219-8420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
743 SPRING ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-219-9000
Provider Business Practice Location Address Fax Number:
770-219-6021
Provider Enumeration Date:
10/04/2016

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: 363LA2100X , with the licence number:  RN2012550 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: RN201550 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: RN201550 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003182231A . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003182231B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04229901 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1304001 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003182231B . This is a "PEACH STATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003182231A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com