Provider Demographics
NPI:1619173630
Name:RUPERT, DOLORES G (RN)
Entity Type:Individual
Prefix:MS
First Name:DOLORES
Middle Name:G
Last Name:RUPERT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WINDING CREEK LANE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625
Mailing Address - Country:US
Mailing Address - Phone:585-218-4257
Mailing Address - Fax:
Practice Address - Street 1:112 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616
Practice Address - Country:US
Practice Address - Phone:585-865-3046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4361141163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01643690Medicaid