Provider Demographics
NPI:1477648376
Name:DURHAM, JUANITA LOUISE (ARNP)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:LOUISE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JUANITA
Other - Middle Name:LOUISE
Other - Last Name:WOOLLUMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1030 N 7TH ST
Mailing Address - Street 2:PO BOX 674
Mailing Address - City:CHARITON
Mailing Address - State:IA
Mailing Address - Zip Code:50049-1206
Mailing Address - Country:US
Mailing Address - Phone:641-217-9115
Mailing Address - Fax:641-217-9137
Practice Address - Street 1:1030 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHARITON
Practice Address - State:IA
Practice Address - Zip Code:50049-1206
Practice Address - Country:US
Practice Address - Phone:641-217-9115
Practice Address - Fax:641-217-9137
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA089687363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1477648376Medicaid
IA1737593Medicaid
IA251859OtherMIDLANDS CHOICE
IA03644OtherWELLMARK
IAI69510025Medicare PIN
IAI20190Medicare PIN
IAQ73795Medicare UPIN
IA1737593Medicaid