Provider Demographics
NPI:1306840913
Name:RUDESYLE, DONNA MAE (NP)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MAE
Last Name:RUDESYLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N VAN DIEN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2726
Mailing Address - Country:US
Mailing Address - Phone:201-447-8154
Mailing Address - Fax:201-251-3236
Practice Address - Street 1:223 N VAN DIEN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2726
Practice Address - Country:US
Practice Address - Phone:201-447-8154
Practice Address - Fax:201-251-3236
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN03817400363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8486204Medicaid
NJ8486204Medicaid