Provider Demographics
NPI:1316567639
Name:GULLEDGE, JUDY R
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:R
Last Name:GULLEDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 MYRTLE LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29709-5153
Mailing Address - Country:US
Mailing Address - Phone:843-680-2633
Mailing Address - Fax:
Practice Address - Street 1:74 MYRTLE LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709-5153
Practice Address - Country:US
Practice Address - Phone:843-680-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC45872163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse