Provider Demographics
NPI:1740255900
Name:HALEY, JUDITH B (CPNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:B
Last Name:HALEY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-534-8998
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-535-3611
Practice Address - Fax:770-535-7092
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN139047363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA303398OtherWELLCARE
GA000820388EMedicaid
GA000820388CMedicaid
GA303396OtherWELLCARE
GA000820388HMedicaid
GA303397OtherWELLCARE
GA000820388GMedicaid
GA10032985OtherAMERIGROUP
GA303384OtherWELLCARE