Provider Demographics
NPI:1932474681
Name:DUDLEY, ERICA WARE
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:WARE
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 1:3408 HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-3636
Mailing Address - Country:US
Mailing Address - Phone:706-498-0924
Mailing Address - Fax:
Practice Address - Street 1:3408 HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-3636
Practice Address - Country:US
Practice Address - Phone:706-498-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003813133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered