Provider Demographics
NPI:1609321439
Name:RUDDY, STACI L (FNP-C)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:L
Last Name:RUDDY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:L
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9480 BRIAR VILLAGE PT STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9480 BRIAR VILLAGE PT STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7923
Practice Address - Country:US
Practice Address - Phone:719-278-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0992511-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily