Provider Demographics
NPI:1871268797
Name:PAGE, JUDY MARLENA (NP)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:MARLENA
Last Name:PAGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:MARLI
Other - Middle Name:
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:5241 GUM CREEK CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-9205
Mailing Address - Country:US
Mailing Address - Phone:404-456-3847
Mailing Address - Fax:
Practice Address - Street 1:4186 MILL ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2559
Practice Address - Country:US
Practice Address - Phone:678-625-8317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN223429207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine