Provider Demographics
NPI:1750068060
Name:HUDSON, JUANITA NICHOLE
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:NICHOLE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 SAINT CHARLES DR
Mailing Address - Street 2:
Mailing Address - City:GUYTON
Mailing Address - State:GA
Mailing Address - Zip Code:31312-5380
Mailing Address - Country:US
Mailing Address - Phone:912-507-6249
Mailing Address - Fax:
Practice Address - Street 1:15 SAINT CHARLES DR
Practice Address - Street 2:
Practice Address - City:GUYTON
Practice Address - State:GA
Practice Address - Zip Code:31312-5380
Practice Address - Country:US
Practice Address - Phone:912-507-6249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA932083173172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver