Provider Demographics
NPI:1730814633
Name:JUDGE, JEANINE MARIE
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:MARIE
Last Name:JUDGE
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 1:2239 S ATLANTA ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-3904
Mailing Address - Country:US
Mailing Address - Phone:714-609-2564
Mailing Address - Fax:
Practice Address - Street 1:2239 S ATLANTA ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-3904
Practice Address - Country:US
Practice Address - Phone:714-609-2564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021642363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics