Provider Demographics
NPI:1891959656
Name:RUDOLPH, ELLEN JEAN (LPN)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:JEAN
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4642
Mailing Address - Country:US
Mailing Address - Phone:508-746-1604
Mailing Address - Fax:508-746-1604
Practice Address - Street 1:242 SUMMER ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4642
Practice Address - Country:US
Practice Address - Phone:508-746-1604
Practice Address - Fax:508-746-1604
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA66877164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse