Provider Demographics
NPI:1346888690
Name:RUDDY, COLLEEN (VISION SPECIALIST)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:RUDDY
Suffix:
Gender:F
Credentials:VISION SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-0810
Mailing Address - Country:US
Mailing Address - Phone:570-575-5421
Mailing Address - Fax:
Practice Address - Street 1:205 GLENBURN RD
Practice Address - Street 2:
Practice Address - City:CLARKS GREEN
Practice Address - State:PA
Practice Address - Zip Code:18411-2534
Practice Address - Country:US
Practice Address - Phone:570-575-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No253Z00000XAgenciesIn Home Supportive Care