Provider Demographics
NPI:1871188235
Name:DUDLEY, BETH GABRIELLE (PMHNP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:GABRIELLE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 OPUS PL STE 110
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1164
Mailing Address - Country:US
Mailing Address - Phone:888-279-0002
Mailing Address - Fax:866-638-0302
Practice Address - Street 1:4753 NORTH BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640
Practice Address - Country:US
Practice Address - Phone:888-279-0002
Practice Address - Fax:866-638-0302
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1158128163W00000X
KY3016425363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty