Provider Demographics
NPI:1356891220
Name:MARDER, JUDITH LAUREN (AGACNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LAUREN
Last Name:MARDER
Suffix:
Gender:F
Credentials:AGACNP, FNP-BC
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-219-9000
Practice Address - Fax:770-219-6021
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN2012550363LA2100X
GARN201550363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003182231AOtherPEACH STATE
GA003182231BMedicaid
GA04229901OtherAMERIGROUP
GA1304001OtherWELLCARE
GA003182231BOtherPEACH STATE
GA003182231AMedicaid
GA003182231BMedicaid