Healthcare Provider Details

I. General information

NPI: 1740364355
Provider Name (Legal Business Name): JUDY STALEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SAWDUST RD
SPRING TX
77380-2272
US

IV. Provider business mailing address

9 GREENWAY PLZ STE 2950
HOUSTON TX
77046-0924
US

V. Phone/Fax

Practice location:
  • Phone: 281-419-3162
  • Fax:
Mailing address:
  • Phone: 713-580-9463
  • Fax: 713-358-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number041164136
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number450504
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: