Provider Demographics
NPI:1134502511
Name:RUDISELL, SHANICA (RN)
Entity Type:Individual
Prefix:
First Name:SHANICA
Middle Name:
Last Name:RUDISELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 CORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13205-1039
Mailing Address - Country:US
Mailing Address - Phone:315-450-3281
Mailing Address - Fax:
Practice Address - Street 1:538 CORTLAND AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-1039
Practice Address - Country:US
Practice Address - Phone:315-450-3281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-03
Last Update Date:2015-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 664889163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse