Provider Demographics
NPI:1164420170
Name:WADDELL, JUDITH A (ARNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:WADDELL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 WILKINSON TRCE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-3404
Mailing Address - Country:US
Mailing Address - Phone:270-781-4043
Mailing Address - Fax:270-781-4196
Practice Address - Street 1:990 WILKINSON TRCE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3404
Practice Address - Country:US
Practice Address - Phone:270-781-4043
Practice Address - Fax:270-781-4196
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2742363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78008794Medicaid
KYP28881Medicare UPIN
KY78008794Medicaid