Provider Demographics
NPI:1740008366
Name:DUDLEY, SHANE (RDN)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NY
Mailing Address - Zip Code:13605-1124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 PRATT ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4300
Practice Address - Country:US
Practice Address - Phone:315-785-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered