Provider Demographics
NPI:1598735250
Name:HELLER, JUDITH ANN
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:HELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:KINGSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3306 LAKE ARIEL HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431
Mailing Address - Country:US
Mailing Address - Phone:570-253-0148
Mailing Address - Fax:
Practice Address - Street 1:3306 LAKE ARIEL HIGHWAY
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431
Practice Address - Country:US
Practice Address - Phone:570-253-0148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP006386B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P34830Medicare UPIN
PA049139Medicare ID - Type Unspecified