Healthcare Provider Details

I. General information

NPI: 1619998713
Provider Name (Legal Business Name): CONNIE J JUDD ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 16TH AVE N
NAMPA ID
83687-4058
US

IV. Provider business mailing address

223 16TH AVE N
NAMPA ID
83687-4058
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7869
  • Fax: 208-466-5359
Mailing address:
  • Phone: 208-466-7869
  • Fax: 208-466-5359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberCNS-65A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: