Provider Demographics
NPI:1710350608
Name:RUDNICKI, AMANDA ELYSE (CNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELYSE
Last Name:RUDNICKI
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ELYSE
Other - Last Name:KOTHEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:715 E WESTERN RESERVE RD
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-3358
Mailing Address - Country:US
Mailing Address - Phone:330-726-3204
Mailing Address - Fax:330-729-9316
Practice Address - Street 1:715 E WESTERN RESERVE RD
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-3358
Practice Address - Country:US
Practice Address - Phone:330-726-3204
Practice Address - Fax:330-729-9316
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.18485363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0151502Medicaid