Provider Demographics
NPI:1669750741
Name:DUDLEY, DIANE ELIZABETH
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:ELIZABETH
Last Name:DUDLEY
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 1:746 NW LOOP 410
Mailing Address - Street 2:T-2467
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5609
Mailing Address - Country:US
Mailing Address - Phone:210-424-2302
Mailing Address - Fax:210-424-2312
Practice Address - Street 1:746 NW LOOP 410
Practice Address - Street 2:T-2467
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5609
Practice Address - Country:US
Practice Address - Phone:210-424-2302
Practice Address - Fax:210-424-2312
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-24
Last Update Date:2011-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist