Provider Demographics
NPI:1770945263
Name:KUDOJA, MARY N (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:N
Last Name:KUDOJA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5252
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:10151 SE SUNNYSIDE RD STE 100
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5705
Practice Address - Country:US
Practice Address - Phone:503-659-0880
Practice Address - Fax:503-659-0880
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10001428363LF0000X
WI6843-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100054720Medicaid