Provider Demographics
NPI:1952373524
Name:BRANSCOM, JUDY J (FNP)
Entity type:Individual
Prefix:MS
First Name:JUDY
Middle Name:J
Last Name:BRANSCOM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4127
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015
Mailing Address - Country:US
Mailing Address - Phone:540-981-9394
Mailing Address - Fax:540-344-7154
Practice Address - Street 1:2850 KEAGY ROAD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-375-9375
Practice Address - Fax:540-375-9376
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001104398363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010041414Medicaid
VA000571N05Medicare ID - Type Unspecified
VA010041414Medicaid