Provider Demographics
NPI:1629194428
Name:RUPP, GERALDINE (CNP)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:
Last Name:RUPP
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7070 E DR N
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-8562
Mailing Address - Country:US
Mailing Address - Phone:269-660-1670
Mailing Address - Fax:269-660-0666
Practice Address - Street 1:306 E MAUMEE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2038
Practice Address - Country:US
Practice Address - Phone:269-660-1670
Practice Address - Fax:269-660-0666
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07202163WG0000X
MI4704189142363L00000X
IN71005085A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH500030618OtherRAILROAD
OH1092419Medicaid
MIM97310027Medicare PIN
OH500030618OtherRAILROAD
ININ2214002Medicare PIN
OH11642Medicare PIN