Provider Demographics
NPI:1316058084
Name:DUDLEY, LYNN MARIE (PA)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10005 OLD COLUMBIA RD STE P170
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1727
Mailing Address - Country:US
Mailing Address - Phone:410-312-5280
Mailing Address - Fax:877-844-1423
Practice Address - Street 1:10005 OLD COLUMBIA RD STE P170
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1727
Practice Address - Country:US
Practice Address - Phone:410-312-5280
Practice Address - Fax:877-844-1423
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002980363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCQ38237Medicare UPIN