Provider Demographics
NPI:1598357584
Name:RUDISILL, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:RUDISILL
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:PO BOX 143
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60974-0143
Mailing Address - Country:US
Mailing Address - Phone:815-473-4329
Mailing Address - Fax:
Practice Address - Street 1:1334 N 2080 E RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:IL
Practice Address - Zip Code:60974-6097
Practice Address - Country:US
Practice Address - Phone:815-473-4329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider