Provider Demographics
NPI:1194759464
Name:RACINE, JUDY K (NP)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:K
Last Name:RACINE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25455 BARTON RD
Mailing Address - Street 2:SUITE 102B
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3128
Mailing Address - Country:US
Mailing Address - Phone:909-558-2808
Mailing Address - Fax:
Practice Address - Street 1:25455 BARTON RD
Practice Address - Street 2:SUITE 102B
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3128
Practice Address - Country:US
Practice Address - Phone:909-558-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP10548363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q62934Medicare UPIN
CAZZZ18064ZMedicare PIN