Provider Demographics
NPI:1336717552
Name:OLDHAM, JUDY A (FOSTER PARENT)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:OLDHAM
Suffix:
Gender:F
Credentials:FOSTER PARENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 ANGELES RD
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-3526
Mailing Address - Country:US
Mailing Address - Phone:407-506-6067
Mailing Address - Fax:407-268-0864
Practice Address - Street 1:246 ANGELES RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-3526
Practice Address - Country:US
Practice Address - Phone:407-506-6067
Practice Address - Fax:407-268-0864
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10098851003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109885100Medicaid