MEDICARE: MR. MARK DUDLEY APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	1361364405	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P33212	OTHER	UT	MEDICARE ADVANTAGE PLUS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	94293834884047A017	OTHER	UT	CHAMPUS
2	107002906101	OTHER	UT	INTERMOUNTAIN HEALTH CARE
3	262137	OTHER	UT	DESERET MUTUAL

General Provider Information

NPI Number	:	1144223678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK DUDLEY APRN

Provider Business Mailing Address
First Line	:	2386 SNOW MOUNTAIN DR
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-1753
Country	:	US
Telephone Number	:	801-733-4376
Fax Number	:	801-466-3195

Provider Business Practice Location Address
First Line	:	1399 S 700 E STE 11B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2149
Country	:	US
Telephone Number	:	801-918-9890
Fax Number	:	801-466-3195

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2005
Last Update Date	:	07/08/2007

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Directions to “ MR. MARK DUDLEY APRN” Practice Location

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