Provider Demographics
NPI:1740758937
Name:RUDE, MARANDA ELYSE
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:ELYSE
Last Name:RUDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 N ENDERLY AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-1164
Mailing Address - Country:US
Mailing Address - Phone:765-338-8135
Mailing Address - Fax:
Practice Address - Street 1:1000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1948
Practice Address - Country:US
Practice Address - Phone:317-745-4451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002206A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer