Provider Demographics
NPI:1073893954
Name:MCINTOSH, JUDITH (NP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:513 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3418
Practice Address - Country:US
Practice Address - Phone:765-453-7702
Practice Address - Fax:765-453-7825
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28069569A163W00000X
IN71003759A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201038600Medicaid
IN000000735838OtherANTHEM PROVIDER NUMBER
INP01000906Medicare PIN
IN201038600Medicaid