Healthcare Provider Details

I. General information

NPI: 1639880628
Provider Name (Legal Business Name): ALYSSA SABREE DUDLEY MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 S WATER TOWER PL
MOUNT VERNON IL
62864-2349
US

IV. Provider business mailing address

2401 W MAIN ST
MARION IL
62959-1188
US

V. Phone/Fax

Practice location:
  • Phone: 618-246-2910
  • Fax: 618-242-8240
Mailing address:
  • Phone: 618-997-5311
  • Fax: 618-242-8240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041489008
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: