Provider Demographics
NPI:1487613915
Name:HART, JUDITH L (CRNA)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:HART
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 TUGALOO BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690
Mailing Address - Country:US
Mailing Address - Phone:864-834-0116
Mailing Address - Fax:
Practice Address - Street 1:200 FLEETWOOD DR
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640
Practice Address - Country:US
Practice Address - Phone:864-442-7200
Practice Address - Fax:864-442-7821
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN260367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q31815Medicare UPIN