Provider Demographics
NPI:1356368989
Name:MEDLEY, JUDITH (MSN, RN, FNP, CPNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:MSN, RN, FNP, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-0157
Mailing Address - Country:US
Mailing Address - Phone:573-663-2313
Mailing Address - Fax:573-663-2322
Practice Address - Street 1:315 W MULBERRY
Practice Address - Street 2:
Practice Address - City:PILOT KNOB
Practice Address - State:MO
Practice Address - Zip Code:63663
Practice Address - Country:US
Practice Address - Phone:573-546-0602
Practice Address - Fax:573-546-0624
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO086052363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423134865Medicaid
P04656Medicare UPIN
MO423134865Medicaid