Provider Demographics
NPI:1730489436
Name:RUDD, KRISTA BUZZELL (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:BUZZELL
Last Name:RUDD
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 E TERRY ST
Mailing Address - Street 2:APT A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2767
Mailing Address - Country:US
Mailing Address - Phone:208-234-1274
Mailing Address - Fax:
Practice Address - Street 1:4650 HAWTHORNE RD
Practice Address - Street 2:STE 3B
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2376
Practice Address - Country:US
Practice Address - Phone:208-237-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1486235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist