Provider Demographics
NPI:1003686320
Name:RUDDER, VICTORIA JEAN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JEAN
Last Name:RUDDER
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 1:109 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:SISTERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26175-1501
Mailing Address - Country:US
Mailing Address - Phone:304-780-4548
Mailing Address - Fax:
Practice Address - Street 1:109 CARTER ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1501
Practice Address - Country:US
Practice Address - Phone:304-780-4548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV1821206228Medicaid
WV125553494Medicaid