Stephanie Dudley

  Countryside Regional 
 5790 O'Donavan Blvd 
 Walker, LA, 70795-6351 
 P: (225)379-1312 
 F: (279)380-1314 
 Receipt 
 PATIENT NAME
 Stephanie Dudley (Case: Pneumonia) 
 D.O.B:2014 December 24
 Date of Transaction: 2019 July 22 
 4943 Stein Dale
Jacksonburgh, MO 37592 
 (985) 614-3948 
 (939) 507-9456 
 SERVICE DATE
 Payment 
 Description 
 Amount Due 
 Amount Paid 
 Paid Method 
 Auth / Check 
 Type 
 Credit Type 
 # 
 2018 December 08 
 Office Visit 
 Copay 
 $38.00 
 38 
 Cash 
 Copay 
 Total: $38.00 
 ELECTRONICALLY SIGNED BY Dr Jonathan Miller, M.D., 2022 March 23 8:22 AM 
 Thank you for your business! 
 Date: 2015/03/18 
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