Healthcare Provider Details

I. General information

NPI: 1285091405
Provider Name (Legal Business Name): JUDITH LUCILLE NEALY L.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 GREENWOOD AVE
JACKSON MI
49203
US

IV. Provider business mailing address

1515 GREENWOOD AVE
JACKSON MI
49203
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-5710
  • Fax:
Mailing address:
  • Phone: 517-787-5710
  • Fax: 517-787-9855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703041502
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: