Provider Demographics
NPI:1811133622
Name:BAIN, JUDY B (NP)
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:B
Last Name:BAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1022 GREYSTONE SQ
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-3580
Mailing Address - Country:US
Mailing Address - Phone:731-300-2001
Mailing Address - Fax:731-240-8095
Practice Address - Street 1:1022 GREYSTONE SQ
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3580
Practice Address - Country:US
Practice Address - Phone:731-300-2001
Practice Address - Fax:731-240-8095
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN133680363L00000X
TN13649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNCL6903OtherTGBA, LLC
TN1513747Medicaid
TN4258972OtherBLUE CROSS BLUE SHIELD TN
103I507006Medicare PIN