Provider Demographics
NPI:1285806109
Name:STUCK, JUDY (APRN)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:STUCK
Suffix:
Gender:F
Credentials:APRN
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 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7306
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:1850 LAUREL STREET
Practice Address - Street 2:SUITE 1A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29220-0001
Practice Address - Country:US
Practice Address - Phone:803-376-5982
Practice Address - Fax:803-376-5982
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN275363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1415Medicaid