Provider Demographics
NPI:1124132378
Name:LAURIDSEN, JUDITH A (CNP)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:A
Last Name:LAURIDSEN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 RIVERSIDE DRIVE
Mailing Address - Street 2:PO BOX 629
Mailing Address - City:POPLAR
Mailing Address - State:MT
Mailing Address - Zip Code:59255
Mailing Address - Country:US
Mailing Address - Phone:406-768-5171
Mailing Address - Fax:406-768-6161
Practice Address - Street 1:210 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:POPLAR
Practice Address - State:MT
Practice Address - Zip Code:59255
Practice Address - Country:US
Practice Address - Phone:406-768-5171
Practice Address - Fax:406-768-6161
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN09057363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0433238Medicaid
SD6827120Medicaid
R95892Medicare UPIN