Provider Demographics
NPI:1679063275
Name:CONGRAVE RUDE, CHENIN LEE (APN)
Entity Type:Individual
Prefix:MRS
First Name:CHENIN
Middle Name:LEE
Last Name:CONGRAVE RUDE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:345 EXECUTIVE PKWY STE M4
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5291
Mailing Address - Country:US
Mailing Address - Phone:815-381-8514
Mailing Address - Fax:815-381-8665
Practice Address - Street 1:345 EXECUTIVE PKWY STE M4
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5291
Practice Address - Country:US
Practice Address - Phone:815-381-8514
Practice Address - Fax:815-381-8665
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041388930163W00000X
IL209017674363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse