Provider Demographics
NPI:1548258452
Name:ANDERSON, JUDITH A (CPNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:MISS
Other - First Name:JUDITH
Other - Middle Name:A
Other - Last Name:KUPKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11550 POEMA PL
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-1119
Mailing Address - Country:US
Mailing Address - Phone:317-937-5362
Mailing Address - Fax:
Practice Address - Street 1:15210 PARTHENIA ST
Practice Address - Street 2:
Practice Address - City:INORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343
Practice Address - Country:US
Practice Address - Phone:818-895-3100
Practice Address - Fax:818-963-9464
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002231A363LP0200X
CA22789363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200845120Medicaid
145590P5Medicare ID - Type Unspecified
IN200845120Medicaid