Provider Demographics
NPI:1700828480
Name:RUDOLPH, NANNETTE GAY (CRNA)
Entity Type:Individual
Prefix:
First Name:NANNETTE
Middle Name:GAY
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:NANNETTE
Other - Middle Name:GAY
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:418 GRAND PARK DR
Mailing Address - Street 2:SUITE 315
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26105-4000
Mailing Address - Country:US
Mailing Address - Phone:304-428-3500
Mailing Address - Fax:304-422-7900
Practice Address - Street 1:1933 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BELPRE
Practice Address - State:OH
Practice Address - Zip Code:45714-2041
Practice Address - Country:US
Practice Address - Phone:304-428-3500
Practice Address - Fax:304-422-7900
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNA-05174367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000384706OtherANTHEM BLUE CROSS
WV0066014000Medicaid
P00141438OtherRAILROAD MEDICARE
1065483OtherBRICKSTREET W/C
001714638OtherMOUNTAIN STATE BLUE CROSS
OH2141659Medicaid
9350088OtherPRIVATE HEALTH CARE SYS.
W46043OtherTHE HEALTH PLAN
1065483OtherBRICKSTREET W/C
OH2141659Medicaid