Provider Demographics
NPI:1750704714
Name:FRIDGEN, JUDYANN M
Entity type:Individual
Prefix:
First Name:JUDYANN
Middle Name:M
Last Name:FRIDGEN
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 1:6512 39TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:NELSON
Mailing Address - State:MN
Mailing Address - Zip Code:56355-8175
Mailing Address - Country:US
Mailing Address - Phone:320-493-9872
Mailing Address - Fax:320-852-9933
Practice Address - Street 1:6512 39TH AVE NE
Practice Address - Street 2:
Practice Address - City:NELSON
Practice Address - State:MN
Practice Address - Zip Code:56355-8175
Practice Address - Country:US
Practice Address - Phone:320-493-9872
Practice Address - Fax:320-852-9933
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1069131-1-HCBS253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency