Healthcare Provider Details

I. General information

NPI: 1912922816
Provider Name (Legal Business Name): BONNIE SUE JUDD APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E COMMERCE ST
WAVERLY TN
37185-1629
US

IV. Provider business mailing address

203 E COMMERCE ST
WAVERLY TN
37185-1629
US

V. Phone/Fax

Practice location:
  • Phone: 931-296-5833
  • Fax: 931-296-7388
Mailing address:
  • Phone: 931-296-5833
  • Fax: 931-296-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6534
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: