Provider Demographics
NPI:1851342034
Name:RUTKOWSKI, DEBRA (MS, APRN, BC-FNP, CD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:RUTKOWSKI
Suffix:
Gender:F
Credentials:MS, APRN, BC-FNP, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:UNITED HEALTH SERVICES HOSP INC
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:40 ARCH ST
Practice Address - Street 2:DIABETES EDUCATION AND MANAGEMENT CENTER
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:607-763-6092
Practice Address - Fax:607-763-6677
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333913-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02672099Medicaid
NY02672099Medicaid
RA6386Medicare PIN