Basic Information
| Provider Information | |||||||||
| NPI: | 1457388126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUDY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRAH | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 176 DAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249019302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046474411 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1320 MAPLEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249708016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046476549 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 5580 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3810005440 | 05 | WV | MEDICAID |