Provider Demographics
NPI:1417215542
Name:RUDOLPH, SUSAN K (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:K
Other - Last Name:ZUIDEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:516 CHERRY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4702
Mailing Address - Country:US
Mailing Address - Phone:616-456-6135
Mailing Address - Fax:616-771-9762
Practice Address - Street 1:516 CHERRY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4702
Practice Address - Country:US
Practice Address - Phone:616-456-6135
Practice Address - Fax:616-771-9762
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704155333163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP51090Medicare UPIN