Provider Demographics
NPI:1346578853
Name:RUDISILE, MARYBETH ANDREA (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:MARYBETH
Middle Name:ANDREA
Last Name:RUDISILE
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4437 INNSBRUCK RDG
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9058
Mailing Address - Country:US
Mailing Address - Phone:541-227-3180
Mailing Address - Fax:
Practice Address - Street 1:4437 INNSBRUCK RDG
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9058
Practice Address - Country:US
Practice Address - Phone:541-227-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200842425RN163W00000X, 163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn