=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619088390
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH HAGGARD FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 08/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 RUSSELL ST
-----------------------------------------------------
City | KENNETT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63857-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-717-1332
-----------------------------------------------------
Fax | 573-717-1335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 400
-----------------------------------------------------
City | NEW MADRID
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63869-0400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-748-2404
-----------------------------------------------------
Fax | 573-748-2554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 048374
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------