Provider Demographics
NPI:1104276708
Name:DUDLEY, MICHELLE (AGPCNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SHERATON BLVD STE 290
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1358
Mailing Address - Country:US
Mailing Address - Phone:478-633-8400
Mailing Address - Fax:
Practice Address - Street 1:240 SHERATON BLVD STE 290
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1358
Practice Address - Country:US
Practice Address - Phone:478-633-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN147583363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology