Provider Demographics
NPI:1396848487
Name:SHAFER, JUDY-LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:JUDY-LYNN
Middle Name:
Last Name:SHAFER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WAHOO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-2324
Mailing Address - Country:US
Mailing Address - Phone:860-694-2485
Mailing Address - Fax:
Practice Address - Street 1:491 GOLD STAR HWY
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-445-5107
Practice Address - Fax:860-448-1368
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002332363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004209260Medicaid
500000537Medicare ID - Type Unspecified
CT004209260Medicaid