Provider Demographics
NPI:1972726925
Name:CONLEY, JUDY LEE
Entity Type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:LEE
Last Name:CONLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 LONG FORK RD
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9033
Mailing Address - Country:US
Mailing Address - Phone:740-289-3877
Mailing Address - Fax:740-289-3877
Practice Address - Street 1:4611 LONG FORK RD
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9033
Practice Address - Country:US
Practice Address - Phone:740-289-3877
Practice Address - Fax:740-289-3877
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2591315171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2591315Medicaid