Provider Demographics
NPI:1457680209
Name:DUDLEY, CHRISTINA RENEE (PA)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:RENEE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:R
Other - Last Name:SORRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2080 OAKLEY SEAVER DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1962
Mailing Address - Country:US
Mailing Address - Phone:321-841-6444
Mailing Address - Fax:407-650-1307
Practice Address - Street 1:2080 OAKLEY SEAVER DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1962
Practice Address - Country:US
Practice Address - Phone:321-841-6444
Practice Address - Fax:407-650-1307
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105184363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004453300Medicaid
FLCV045XMedicare PIN
FLCV045WMedicare PIN
FLCV045ZMedicare PIN