Provider Demographics
NPI: | 1245387422 |
---|---|
Name: | BARTLE, JUDY ANN (APRN, BC, FNPGNP) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | JUDY |
Middle Name: | ANN |
Last Name: | BARTLE |
Suffix: | |
Gender: | F |
Credentials: | APRN, BC, FNPGNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 670 MASON RIDGE CENTER DR STE 300 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAINT LOUIS |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63141-8573 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 573-860-6000 |
Mailing Address - Fax: | 573-860-6016 |
Practice Address - Street 1: | 965 MATTOX DR |
Practice Address - Street 2: | |
Practice Address - City: | SULLIVAN |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63080-2365 |
Practice Address - Country: | US |
Practice Address - Phone: | 573-860-6000 |
Practice Address - Fax: | 573-860-6016 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-01-03 |
Last Update Date: | 2022-07-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MO | 113196 | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 1245387422 | Medicaid | |
AR | 175738758 | Medicaid | |
MO | 132300038 | Medicare PIN | |
AR | 175738758 | Medicaid | |
MO | 000080874 | Medicare PIN |