Provider Demographics
NPI:1508397464
Name:RUDNIK, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RUDNIK
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-302-3800
Mailing Address - Fax:
Practice Address - Street 1:8320 W BLUEMOUND RD STE 125
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53213-3367
Practice Address - Country:US
Practice Address - Phone:414-023-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7367-33363LF0000X
WI148933367A00000X
WI7637-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife