=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609434232
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDY WORRELL DNP AGNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2019
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5450 LYNDALE AVE S
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55419-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-256-8225
-----------------------------------------------------
Fax | 612-457-0216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 148 INTERLACHEN RD
-----------------------------------------------------
City | HOPKINS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55343-8524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN1806928-2037590
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | 10711
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------