Provider Demographics
NPI:1235268301
Name:CARPENTER, JUDITH LEE (PA)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:LEE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 COURT STREET
Mailing Address - Street 2:DH KEENE FAMILY MEDICINE
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431
Mailing Address - Country:US
Mailing Address - Phone:802-365-4354
Mailing Address - Fax:802-365-9435
Practice Address - Street 1:590 COURT STREET
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431
Practice Address - Country:US
Practice Address - Phone:603-354-5454
Practice Address - Fax:603-354-6692
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001561164W00000X
VT0550030895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001561OtherLICENSE NUMBER
CT000971OtherLICENSE NUMBER
VT0550030895OtherLICENSE
VT9000369Medicaid
473981Medicare Oscar/Certification
VT9000369Medicaid
0004657Medicare PIN