Provider Demographics
NPI:1538703822
Name:DUDLEY, TASHEKA SHACONNIE
Entity Type:Individual
Prefix:
First Name:TASHEKA
Middle Name:SHACONNIE
Last Name:DUDLEY
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 1:2981 KANELL BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4008
Mailing Address - Country:US
Mailing Address - Phone:573-712-2902
Mailing Address - Fax:
Practice Address - Street 1:2981 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4008
Practice Address - Country:US
Practice Address - Phone:573-712-2902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator