Provider Demographics
NPI:1699042523
Name:ELLISON-RUDDOCK, VASHTINA G (FNP)
Entity Type:Individual
Prefix:MRS
First Name:VASHTINA
Middle Name:G
Last Name:ELLISON-RUDDOCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 OTIS PLACE, NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010
Mailing Address - Country:US
Mailing Address - Phone:202-549-0925
Mailing Address - Fax:
Practice Address - Street 1:2226 WISCONSIN AVE, NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007
Practice Address - Country:US
Practice Address - Phone:202-994-8671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1002387363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCRN1002387OtherCRNP-ADVANCED PRACTICE REGISTERED NURSE
MDR159793OtherCRNP-ADVANCED PRACTICE REGISTERED NURSE