Basic Information
Provider Information | |||||||||
NPI: | 1588028567 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DUDLEY | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | O'NEIL | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 623 S MAIN ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | MOSCOW | ||||||||
State: | ID | ||||||||
PostalCode: | 838432983 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 623 S MAIN ST STE 100 | ||||||||
Address2: |   | ||||||||
City: | MOSCOW | ||||||||
State: | ID | ||||||||
PostalCode: | 838432983 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2088822011 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2016 | ||||||||
LastUpdateDate: | 09/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD60926794 | WA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | M-15297 | ID | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207V00000X | MD60926794 | WA | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.