=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962120196
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITH ANN BURROUGHS NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2022
-----------------------------------------------------
Last Update Date | 08/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 556 CIFFORD MEEKS RD
-----------------------------------------------------
City | COLLINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-536-5534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 556 CIFFORD MEEKS RD
-----------------------------------------------------
City | COLLINS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-536-5534
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN197836
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------