Basic Information
| Provider Information | |||||||||
| NPI: | 1215927751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUDINI | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | BEATRICE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 292 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140521560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166521560 | ||||||||
| FaxNumber: | 7166520018 | ||||||||
| Practice Location | |||||||||
| Address1: | 292 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140521650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166521560 | ||||||||
| FaxNumber: | 7166520018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 06/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0106X | 236991 | NY | N | Nursing Service Providers | Registered Nurse | Occupational Health | 363LA2200X | F-301348-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 00535829001 | 01 | NY | BCBS WNY | OTHER | 1215927751 | 01 | NY | UNIVERA | OTHER | 9512618 | 01 | NY | IHA | OTHER | 03605341 | 05 | NY | MEDICAID |