Provider Demographics
NPI:1184711889
Name:LAGRANGE, JUDY (PT)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:
Last Name:LAGRANGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 GARMAN RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-9307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1234 E DUPONT RD
Practice Address - Street 2:STE 7
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1545
Practice Address - Country:US
Practice Address - Phone:260-490-0940
Practice Address - Fax:260-490-5063
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007944A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000346620OtherANTHEM PIN
IN000000346620OtherANTHEM PIN