Provider Demographics
NPI:1619088390
Name:HAGGARD, JUDITH (FNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:HAGGARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-0400
Mailing Address - Country:US
Mailing Address - Phone:573-748-2404
Mailing Address - Fax:573-748-2554
Practice Address - Street 1:500 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2102
Practice Address - Country:US
Practice Address - Phone:573-717-1332
Practice Address - Fax:573-717-1335
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO048374363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424691103Medicaid
MO424691111Medicaid
S94730Medicare UPIN
MO424691103Medicaid