Provider Demographics
NPI:1912210196
Name:MYERS, JUDY LEE (RN, CNS)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:LEE
Last Name:MYERS
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Gender:F
Credentials:RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:615 1ST AVE NE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2447
Mailing Address - Country:US
Mailing Address - Phone:612-436-0295
Mailing Address - Fax:612-436-0163
Practice Address - Street 1:615 1ST AVE NE
Practice Address - Street 2:SUITE 310
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2447
Practice Address - Country:US
Practice Address - Phone:612-436-0295
Practice Address - Fax:612-436-0163
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN0300363364SP0807X
MNR 187128-3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse