Provider Demographics
NPI:1023993623
Name:RUDOLPH, BAILEY
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:RUDOLPH
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 1:5110 LIBBEY RD
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-9758
Mailing Address - Country:US
Mailing Address - Phone:419-806-9222
Mailing Address - Fax:
Practice Address - Street 1:2130 W CENTRAL AVE STE 105
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3819
Practice Address - Country:US
Practice Address - Phone:419-291-4590
Practice Address - Fax:419-291-4593
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH489659163W00000X
OHAPRN.CNP.0040032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse