Provider Demographics
NPI:1467898395
Name:RUDD, KELLY SHIVEL (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SHIVEL
Last Name:RUDD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 HERSCHEL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3819
Mailing Address - Country:US
Mailing Address - Phone:904-387-4030
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-19
Last Update Date:2013-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9180092367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered