Provider Demographics
NPI:1275287179
Name:IBIDOKUN, JUDITH N (BSN, RN)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:N
Last Name:IBIDOKUN
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 MISTY MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-3997
Mailing Address - Country:US
Mailing Address - Phone:636-720-3090
Mailing Address - Fax:
Practice Address - Street 1:600 BREEZE PARK DR
Practice Address - Street 2:
Practice Address - City:WELDON SPRING
Practice Address - State:MO
Practice Address - Zip Code:63304-9139
Practice Address - Country:US
Practice Address - Phone:636-720-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010039563163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse