Provider Demographics
NPI:1881697704
Name:GARRISON, JUDIE LYNNE (MD)
Entity type:Individual
Prefix:DR
First Name:JUDIE
Middle Name:LYNNE
Last Name:GARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 SOUTHAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7671
Mailing Address - Country:US
Mailing Address - Phone:252-355-2682
Mailing Address - Fax:252-830-5138
Practice Address - Street 1:400 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7244
Practice Address - Country:US
Practice Address - Phone:252-758-6627
Practice Address - Fax:252-830-5138
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-01248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34736OtherBCBS
NC8934736Medicaid
NC34736OtherBCBS
NC2216261Medicare ID - Type Unspecified