Provider Demographics
NPI:1467516187
Name:RUDDLE-FREY, JENNIFER ELIZABETH
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:RUDDLE-FREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-4227
Mailing Address - Country:US
Mailing Address - Phone:410-263-4140
Mailing Address - Fax:
Practice Address - Street 1:6085 MARSHALEE DR
Practice Address - Street 2:110
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6023
Practice Address - Country:US
Practice Address - Phone:410-379-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR135106363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily