Healthcare Provider Details

I. General information

NPI: 1831407865
Provider Name (Legal Business Name): JUDITH MARY LASSEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 N STOCKTON HILL RD
KINGMAN AZ
86401
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-753-1177
  • Fax: 928-753-1178
Mailing address:
  • Phone: 928-522-9879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3817
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: