Provider Demographics
NPI:1093715740
Name:LEWALLEN, JUDITH G (FNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:G
Last Name:LEWALLEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:G
Other - Last Name:KEETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:100 JESSIE JAMES BLVD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64856
Mailing Address - Country:US
Mailing Address - Phone:417-223-7050
Mailing Address - Fax:417-223-7055
Practice Address - Street 1:100 JESSIE JAMES BLVD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:MO
Practice Address - Zip Code:64856
Practice Address - Country:US
Practice Address - Phone:417-223-7050
Practice Address - Fax:417-223-7055
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1028363L00000X
MO085477363LF0000X
ARA03622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner