Provider Demographics
NPI:1023604626
Name:DUDLEY, CARRIE B
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:B
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:PO BOX 2503
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28502-2503
Mailing Address - Country:US
Mailing Address - Phone:252-286-6803
Mailing Address - Fax:
Practice Address - Street 1:603 HEARTWOOD RD
Practice Address - Street 2:
Practice Address - City:GRIMESLAND
Practice Address - State:NC
Practice Address - Zip Code:27837-9787
Practice Address - Country:US
Practice Address - Phone:252-286-6803
Practice Address - Fax:252-643-0408
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFLC-074-051311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home