Provider Demographics
NPI:1912953407
Name:DUDLEY, RETHA S (NP)
Entity Type:Individual
Prefix:MRS
First Name:RETHA
Middle Name:S
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 MCLAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112
Mailing Address - Country:US
Mailing Address - Phone:870-523-5272
Mailing Address - Fax:870-523-4292
Practice Address - Street 1:1200 MCLAIN STREET
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112
Practice Address - Country:US
Practice Address - Phone:870-523-5272
Practice Address - Fax:870-523-4292
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01291363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR500000784OtherRAILROAD MEDICARE
5S847Medicare ID - Type Unspecified
AR500000784OtherRAILROAD MEDICARE