Provider Demographics
NPI:1730357252
Name:KALLEY, JUDITH LYNN
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:KALLEY
Suffix:
Gender:F
Credentials:
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 432
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0432
Mailing Address - Country:US
Mailing Address - Phone:417-231-5780
Mailing Address - Fax:
Practice Address - Street 1:Z H S 4A
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0432
Practice Address - Country:US
Practice Address - Phone:417-231-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2428174400000X
MO174400000X
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist