Provider Demographics
NPI:1043855406
Name:JUDY, MAKENZIE JO
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:JO
Last Name:JUDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 GOLDEN ANTLER LN
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-3130
Mailing Address - Country:US
Mailing Address - Phone:417-658-5308
Mailing Address - Fax:
Practice Address - Street 1:2614 GOLDEN ANTLER LN
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-3130
Practice Address - Country:US
Practice Address - Phone:417-658-5308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT35151208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation