Provider Demographics
NPI:1598252207
Name:DUDLEY, KIM (CMP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:CMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3028 KINGS MANOR DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-6868
Mailing Address - Country:US
Mailing Address - Phone:704-770-6098
Mailing Address - Fax:
Practice Address - Street 1:9208 ARDREY KELL RD STE 14
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0786
Practice Address - Country:US
Practice Address - Phone:704-770-6098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist