Provider Demographics
NPI:1326004763
Name:STREET, JUDY NAOMI (FNP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:NAOMI
Last Name:STREET
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-1440
Mailing Address - Country:US
Mailing Address - Phone:276-935-2677
Mailing Address - Fax:276-935-5775
Practice Address - Street 1:RT 460 EAST GRUNDY PLAZA
Practice Address - Street 2:FAMILY CARE CENTER
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-1440
Practice Address - Country:US
Practice Address - Phone:276-935-2677
Practice Address - Fax:276-935-5775
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164960363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00V683F84Medicare ID - Type Unspecified
P36195Medicare UPIN