Provider Demographics
NPI:1609440080
Name:DUDLEY, INGRID
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:
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 1:3058 HIGHWAY 162
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLTON
Mailing Address - State:FL
Mailing Address - Zip Code:32426-7236
Mailing Address - Country:US
Mailing Address - Phone:850-628-8387
Mailing Address - Fax:
Practice Address - Street 1:3058 HIGHWAY 162
Practice Address - Street 2:
Practice Address - City:CAMPBELLTON
Practice Address - State:FL
Practice Address - Zip Code:32426-7236
Practice Address - Country:US
Practice Address - Phone:850-628-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104411500Medicaid