Provider Demographics
NPI:1407352255
Name:PRAIRIE, JUDITH (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:PRAIRIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:ALBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 896199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6199
Mailing Address - Country:US
Mailing Address - Phone:833-936-1364
Mailing Address - Fax:
Practice Address - Street 1:653 BLUEFIELD ROAD, STE F
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-360-6480
Practice Address - Fax:704-883-3228
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2021-00708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine