Provider Demographics
NPI:1104925692
Name:MAGDZIARZ, JUDITH D (NP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:D
Last Name:MAGDZIARZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-0781
Mailing Address - Country:US
Mailing Address - Phone:815-935-7256
Mailing Address - Fax:815-935-7340
Practice Address - Street 1:1701 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2670
Practice Address - Country:US
Practice Address - Phone:815-935-9395
Practice Address - Fax:815-935-1187
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-118752363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL90881Medicare PIN