Provider Demographics
NPI:1760515845
Name:PRICKETT, JUDITH A (CNP, APRN)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:PRICKETT
Suffix:
Gender:F
Credentials:CNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3768 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8502
Mailing Address - Country:US
Mailing Address - Phone:330-533-8490
Mailing Address - Fax:330-533-8783
Practice Address - Street 1:3768 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8502
Practice Address - Country:US
Practice Address - Phone:330-533-8490
Practice Address - Fax:330-533-8783
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-02586363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2359719Medicaid
OHPRNP10991Medicare PIN