Provider Demographics
NPI:1588028567
Name:DUDLEY, AMY ELIZABETH
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:O'NEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8007
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-0507
Mailing Address - Country:US
Mailing Address - Phone:208-883-2224
Mailing Address - Fax:208-883-6580
Practice Address - Street 1:623 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2983
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60926794207V00000X, 207Q00000X
390200000X
IDM-15297207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program