Healthcare Provider Details

I. General information

NPI: 1588028567
Provider Name (Legal Business Name): AMY ELIZABETH DUDLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY ELIZABETH O'NEIL

II. Dates (important events)

Enumeration Date: 04/06/2016
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 S MAIN ST STE 1
MOSCOW ID
83843-2983
US

IV. Provider business mailing address

PO BOX 8007
MOSCOW ID
83843-0507
US

V. Phone/Fax

Practice location:
  • Phone: 208-882-2011
  • Fax: 208-883-1853
Mailing address:
  • Phone: 208-883-2224
  • Fax: 208-883-6580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-15297
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60926794
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60926794
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: