Provider Demographics
NPI:1619998713
Name:JUDD, CONNIE J (ANP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:JUDD
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 16TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-4058
Mailing Address - Country:US
Mailing Address - Phone:208-466-7869
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:223 16TH AVE N
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-4058
Practice Address - Country:US
Practice Address - Phone:208-466-7869
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNS-65A364SP0808X
AK370363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP62641Medicaid
P55371Medicare UPIN
AKNP62641Medicaid