Provider Demographics
NPI:1578002028
Name:RUDOLPH, MICHELLE H (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:H
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHAWN
Other - Middle Name:MICHELLE
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-858-4512
Practice Address - Street 1:421 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1227
Practice Address - Country:US
Practice Address - Phone:812-426-9545
Practice Address - Fax:812-858-4512
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006957A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner