Healthcare Provider Details

I. General information

NPI: 1972020865
Provider Name (Legal Business Name): BRENDA LEE J HUDSON AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA LEE JACKSON

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-0000
  • Fax:
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0024174172
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0024174172
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024174172
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: