Healthcare Provider Details

I. General information

NPI: 1144223678
Provider Name (Legal Business Name): MARK DUDLEY APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARK DUDLEY

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 S 700 E STE 11B
SALT LAKE CITY UT
84105-2149
US

IV. Provider business mailing address

2386 SNOW MOUNTAIN DR
SANDY UT
84093-1753
US

V. Phone/Fax

Practice location:
  • Phone: 801-918-9890
  • Fax: 801-466-3195
Mailing address:
  • Phone: 801-733-4376
  • Fax: 801-466-3195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number1361364405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: