Provider Demographics
NPI:1821503111
Name:RUTLEDGE, DEMETRIA LAVETTE (APRN-C)
Entity Type:Individual
Prefix:MRS
First Name:DEMETRIA
Middle Name:LAVETTE
Last Name:RUTLEDGE
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10141 BIG BEND RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7419
Mailing Address - Country:US
Mailing Address - Phone:813-397-1270
Mailing Address - Fax:813-397-1271
Practice Address - Street 1:10141 BIG BEND RD STE 101
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578
Practice Address - Country:US
Practice Address - Phone:813-397-1270
Practice Address - Fax:813-397-1271
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9181104363L00000X
FLAPRN9181104363LP2300X
OR10010881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101700500Medicaid