Provider Demographics
NPI:1871504076
Name:HARRIS, JUDITH KAY
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:KAY
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:KAY
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:7348 W 21ST ST N
Mailing Address - Street 2:SUITE 107
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1765
Mailing Address - Country:US
Mailing Address - Phone:316-721-4828
Mailing Address - Fax:316-721-4844
Practice Address - Street 1:7348 W 21ST ST N
Practice Address - Street 2:SUITE 107
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1765
Practice Address - Country:US
Practice Address - Phone:316-721-4828
Practice Address - Fax:316-721-4844
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS44009363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100363930CMedicaid
KS161002OtherBC/BS
KS500021112OtherRAILROAD MEDICARE
KS13309OtherPREFERRED HEALTH SYSTEMS
KS500021112OtherRAILROAD MEDICARE
KS13309OtherPREFERRED HEALTH SYSTEMS