Provider Demographics
NPI:1790719250
Name:DIAL, JUDITH M (FNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:DIAL
Suffix:
Gender:F
Credentials:FNP
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Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:DIVISION OF INFECTIOUS DISEASE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5560
Mailing Address - Fax:601-984-5565
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE/DIVISION OF INFECTIOUS DISEASE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5560
Practice Address - Fax:601-984-5565
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-03-01
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Provider Licenses
StateLicense IDTaxonomies
MSR113920207RI0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1522813Medicaid
MS04054008Medicaid
MS302I508634Medicare PIN
MS04054008Medicaid