Provider Demographics
NPI:1144223678
Name:DUDLEY, MARK (APRN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:DUDLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2386 SNOW MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-1753
Mailing Address - Country:US
Mailing Address - Phone:801-733-4376
Mailing Address - Fax:801-466-3195
Practice Address - Street 1:1399 S 700 E STE 11B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2149
Practice Address - Country:US
Practice Address - Phone:801-918-9890
Practice Address - Fax:801-466-3195
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1361364405364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT94293834884047A017OtherCHAMPUS
UT107002906101OtherINTERMOUNTAIN HEALTH CARE
UT262137OtherDESERET MUTUAL
UTP33212OtherMEDICARE ADVANTAGE PLUS
UT262137OtherDESERET MUTUAL