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General NPI Number Information
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NPI Number | 1407858004
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Entity Type | Individual
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Provider Name | JUDY R MACNICHOLS P.A.-C
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Gender | Female
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Dates
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Enumeration Date | 08/12/2005
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Last Update Date | 02/19/2014
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Provider Practice Location Address
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Address Line | 1070 N. STONE STREET SUITE A
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City | DELAND
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State | FL
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Zip | 32720
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Country | US
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Telephone | 386-943-7100
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Fax | 386-738-8909
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Provider Business Mailing Address
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Address Line | 1070 N STONE ST SUITE A
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City | DELAND
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State | FL
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Zip | 32720-0919
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Country | US
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Telephone | 386-943-7100
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Fax | 386-943-8909
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA3264
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA3264
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License Number State | FL
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