Provider Demographics
NPI:1093458093
Name:DUDLEY-WILSON, IVORY GRACE
Entity Type:Individual
Prefix:MISS
First Name:IVORY
Middle Name:GRACE
Last Name:DUDLEY-WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19617 NITRA AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1708
Mailing Address - Country:US
Mailing Address - Phone:216-532-4919
Mailing Address - Fax:
Practice Address - Street 1:19617 NITRA AVE
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1708
Practice Address - Country:US
Practice Address - Phone:216-532-4919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRV798416343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)