Provider Demographics
NPI:1922354190
Name:DUDLEY, JANIA LETISSE (PA)
Entity Type:Individual
Prefix:
First Name:JANIA
Middle Name:LETISSE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:WALLER
Mailing Address - State:TX
Mailing Address - Zip Code:77484-1176
Mailing Address - Country:US
Mailing Address - Phone:936-931-3448
Mailing Address - Fax:
Practice Address - Street 1:18602 FM 1488 RD
Practice Address - Street 2:SUITE 700
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-8508
Practice Address - Country:US
Practice Address - Phone:281-252-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant