Provider Demographics
NPI:1033752258
Name:KUDLOCK, VANESSA (NP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:KUDLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2398 5TH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-2340
Mailing Address - Country:US
Mailing Address - Phone:605-568-0191
Mailing Address - Fax:605-568-0195
Practice Address - Street 1:2398 5TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-2340
Practice Address - Country:US
Practice Address - Phone:605-568-0191
Practice Address - Fax:605-568-0195
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001659363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner