Healthcare Provider Details

I. General information

NPI: 1770945263
Provider Name (Legal Business Name): MARY N KUDOJA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 SE SUNNYSIDE RD STE 100
CLACKAMAS OR
97015-5705
US

IV. Provider business mailing address

2502 S ASHLAND AVE
GREEN BAY WI
54304-5252
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-0880
  • Fax: 503-659-0880
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10001428
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6843-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: