Provider Demographics
NPI:1689996274
Name:RUDOWSKY, MARY JANE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY JANE
Middle Name:
Last Name:RUDOWSKY
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 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24755 CHAGRIN BLVD
Practice Address - Street 2:345
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5682
Practice Address - Country:US
Practice Address - Phone:216-464-0778
Practice Address - Fax:216-765-1461
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN166982163W00000X
OHCOA1145NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3085012Medicaid
OH3085012Medicaid