Provider Demographics
NPI:1841069911
Name:PHILISTIN, DUDLEY
Entity type:Individual
Prefix:
First Name:DUDLEY
Middle Name:
Last Name:PHILISTIN
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 1:4921 NW 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-3461
Mailing Address - Country:US
Mailing Address - Phone:954-864-0261
Mailing Address - Fax:
Practice Address - Street 1:16821 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-2405
Practice Address - Country:US
Practice Address - Phone:786-953-6534
Practice Address - Fax:786-250-1938
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-29
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA214556376K00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No376K00000XNursing Service Related ProvidersNurse's Aide