Provider Demographics
NPI:1811162183
Name:MOOREHEAD, JUDITH MAE
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:MAE
Last Name:MOOREHEAD
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 1:15375 SE 156TH PLACE RD
Mailing Address - Street 2:
Mailing Address - City:WEIRSDALE
Mailing Address - State:FL
Mailing Address - Zip Code:32195-2218
Mailing Address - Country:US
Mailing Address - Phone:352-821-4082
Mailing Address - Fax:
Practice Address - Street 1:15375 SE 156TH PLACE RD
Practice Address - Street 2:
Practice Address - City:WEIRSDALE
Practice Address - State:FL
Practice Address - Zip Code:32195-2218
Practice Address - Country:US
Practice Address - Phone:352-821-4082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230291800Medicaid