Provider Demographics
NPI:1912922816
Name:JUDD, BONNIE SUE (APN)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:SUE
Last Name:JUDD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-1629
Mailing Address - Country:US
Mailing Address - Phone:931-296-5833
Mailing Address - Fax:931-296-7388
Practice Address - Street 1:203 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-1629
Practice Address - Country:US
Practice Address - Phone:931-296-5833
Practice Address - Fax:931-296-7388
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6534363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36404231Medicaid
TN4157094OtherBCBS OF TN PIN
TNQ46888Medicare UPIN
TN36404231Medicare PIN