Provider Demographics
NPI:1346325222
Name:DUDLEY, NICHOLAS VINCENT (DOM)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:VINCENT
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 RAMBLER ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314
Mailing Address - Country:US
Mailing Address - Phone:304-415-5464
Mailing Address - Fax:
Practice Address - Street 1:888 OAKWOOD ROAD
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314
Practice Address - Country:US
Practice Address - Phone:304-415-5464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV96181171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist