Healthcare Provider Details

I. General information

NPI: 1972156735
Provider Name (Legal Business Name): ASHLEY JOANN JUDD LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

104 W LAFAYETTE ST
VERSAILLES MO
65084-1346
US

IV. Provider business mailing address

16766 S NEBO DR
VERSAILLES MO
65084-4532
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5438
  • Fax: 573-378-7375
Mailing address:
  • Phone: 573-789-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2009005365
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: