Provider Demographics
NPI:1710695937
Name:JUDGE, SHANAZ NACY (PMHNP)
Entity Type:Individual
Prefix:
First Name:SHANAZ
Middle Name:NACY
Last Name:JUDGE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:SHAHNAZ
Other - Middle Name:NACY
Other - Last Name:JUDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:3611 S BAINBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8753
Mailing Address - Country:US
Mailing Address - Phone:812-325-0391
Mailing Address - Fax:
Practice Address - Street 1:3600 N PROW RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-1616
Practice Address - Country:US
Practice Address - Phone:812-331-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71013275A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health