Provider Demographics
NPI:1376615658
Name:RUDDY, IRIS L (NP)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:L
Last Name:RUDDY
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 1:2700 N CENTRAL AVE STE 1050
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1217
Mailing Address - Country:US
Mailing Address - Phone:602-266-8402
Mailing Address - Fax:602-264-0887
Practice Address - Street 1:2700 N CENTRAL AVE STE 1050
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1217
Practice Address - Country:US
Practice Address - Phone:602-266-8402
Practice Address - Fax:602-264-0887
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN069361363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ969553Medicaid
Z107379Medicare PIN
AZ969553Medicaid