Healthcare Provider Details

I. General information

NPI: 1013018654
Provider Name (Legal Business Name): VIVIAN DUDLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N OLD HWY 66
BOURBON MO
65441
US

IV. Provider business mailing address

125 N OLD HWY 66
BOURBON MO
65441
US

V. Phone/Fax

Practice location:
  • Phone: 573-679-2006
  • Fax: 573-679-2009
Mailing address:
  • Phone: 573-679-2006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number142760
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: