Provider Demographics
NPI:1003960295
Name:HUMPHREYS, JUDY (NP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:1287 US HIGHWAY 41BYP S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34237-9026
Practice Address - Country:US
Practice Address - Phone:941-244-5706
Practice Address - Fax:941-800-4342
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX701927363L00000X
FLARNP9173689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198164903Medicaid
TX198164902Medicaid
TX8L3375Medicare PIN
FLIS976ZMedicare PIN
TX198164903Medicaid