MEDICARE: DUDLEY G ELMORE III RN,FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	18199	CA

General Provider Information

NPI Number	:	1568620375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUDLEY G ELMORE III RN,FNP

Provider Business Mailing Address
First Line	:	PO BOX 232410
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92193-2410
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 W ARBOR DRIVE
Second Line	:	MC 8401
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-8401
Country	:	US
Telephone Number	:	619-543-5870
Fax Number	:	619-543-7785

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/29/2008
Last Update Date	:	10/16/2018

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