Provider Demographics
NPI:1508538000
Name:RUDBERG, AMY A (LIC ACUPUNCTURIST)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:A
Last Name:RUDBERG
Suffix:
Gender:F
Credentials:LIC ACUPUNCTURIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 N ASTOR ST APT 5SE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-6712
Mailing Address - Country:US
Mailing Address - Phone:312-944-6353
Mailing Address - Fax:
Practice Address - Street 1:1555 N ASTOR ST APT 5SE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-6712
Practice Address - Country:US
Practice Address - Phone:312-944-6353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-02
Last Update Date:2021-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN227.019923225700000X
IL198.001545171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist