Provider Demographics
NPI:1356182851
Name:DUDLEY, ANTOINETTE
Entity type:Individual
Prefix:
First Name:ANTOINETTE
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 1:12114 SOIKA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-3182
Mailing Address - Country:US
Mailing Address - Phone:216-246-5198
Mailing Address - Fax:
Practice Address - Street 1:12114 SOIKA AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-3182
Practice Address - Country:US
Practice Address - Phone:216-246-5198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHRR962306171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator