Provider Demographics
NPI:1730577438
Name:RUDD, ELIZABETH (NP, RN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:RUDD
Suffix:
Gender:F
Credentials:NP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602478
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2478
Mailing Address - Country:US
Mailing Address - Phone:704-863-9700
Mailing Address - Fax:704-548-0927
Practice Address - Street 1:101 E W T HARRIS BLVD
Practice Address - Street 2:SUITE 5002
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3485
Practice Address - Country:US
Practice Address - Phone:704-863-9700
Practice Address - Fax:704-548-0927
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-03
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN242930363LA2200X
NC276242363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1730577438Medicaid
NCNCN686AMedicare PIN