Provider Demographics
NPI:1588663900
Name:KING, JUDITH (CFNP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 NE OUTLOOK AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1412
Mailing Address - Country:US
Mailing Address - Phone:541-474-5665
Mailing Address - Fax:541-474-4435
Practice Address - Street 1:214 NE OUTLOOK AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1412
Practice Address - Country:US
Practice Address - Phone:541-474-5665
Practice Address - Fax:547-474-4435
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000037306N1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR074450Medicaid
OR108613Medicare ID - Type Unspecified
OR074450Medicaid