=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154621613
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUDITH A KING MN FNP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 12/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 124 NW MIDLAND AVE
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-474-5665
-----------------------------------------------------
Fax | 541-474-4435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 124 NW MIDLAND AVE STE 107
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97526-1269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-474-5665
-----------------------------------------------------
Fax | 541-474-4435
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | MS. JUDITH A KING
-----------------------------------------------------
Credential | FAMILY NURSE PRACTIT
-----------------------------------------------------
Telephone | 541-474-5665
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 000037306N1
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------