Healthcare Provider Details

I. General information

NPI: 1619088390
Provider Name (Legal Business Name): JUDITH HAGGARD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RUSSELL ST
KENNETT MO
63857-2102
US

IV. Provider business mailing address

PO BOX 400
NEW MADRID MO
63869-0400
US

V. Phone/Fax

Practice location:
  • Phone: 573-717-1332
  • Fax: 573-717-1335
Mailing address:
  • Phone: 573-748-2404
  • Fax: 573-748-2554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number048374
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: