Provider Demographics
NPI:1144413949
Name:RUDNICKI-ROBERTS, LEONA (MA)
Entity Type:Individual
Prefix:
First Name:LEONA
Middle Name:
Last Name:RUDNICKI-ROBERTS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13500 SUTTON PARK DR S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-5251
Mailing Address - Country:US
Mailing Address - Phone:904-821-5547
Mailing Address - Fax:904-821-5548
Practice Address - Street 1:13500 SUTTON PARK DR S
Practice Address - Street 2:SUITE 102
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-5251
Practice Address - Country:US
Practice Address - Phone:904-821-5547
Practice Address - Fax:904-821-5548
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA25132225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist