Provider Demographics
NPI:1821465246
Name:HUDSON, FANNIE (RN, CASE MANAGER)
Entity Type:Individual
Prefix:MRS
First Name:FANNIE
Middle Name:
Last Name:HUDSON
Suffix:
Gender:F
Credentials:RN, CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 TURNBULL BAY RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-6076
Mailing Address - Country:US
Mailing Address - Phone:386-290-2216
Mailing Address - Fax:386-427-6270
Practice Address - Street 1:1376 TURNBULL BAY RD
Practice Address - Street 2:SUITE 403
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-6076
Practice Address - Country:US
Practice Address - Phone:386-290-2216
Practice Address - Fax:386-427-6270
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2015-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011833700Medicaid