Provider Demographics
NPI:1043452972
Name:RUDOLPH, AMANDA B (CPNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-5210
Mailing Address - Country:US
Mailing Address - Phone:504-887-1133
Mailing Address - Fax:
Practice Address - Street 1:1011 W GROVE ST STE 120
Practice Address - Street 2:
Practice Address - City:KAUFMAN
Practice Address - State:TX
Practice Address - Zip Code:75142-1883
Practice Address - Country:US
Practice Address - Phone:972-932-1319
Practice Address - Fax:972-932-1396
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05388363L00000X
TX162093363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09079528Medicaid
LA1552992Medicaid
LA1552992Medicaid