Provider Demographics
NPI:1912038605
Name:RUDOLPH, ELIZABETH T (ARNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:T
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 STONE WAY N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7420
Mailing Address - Country:US
Mailing Address - Phone:206-461-3614
Mailing Address - Fax:206-634-0094
Practice Address - Street 1:4319 STONE WAY N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-7420
Practice Address - Country:US
Practice Address - Phone:206-461-3614
Practice Address - Fax:206-634-0094
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003629363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9618737Medicaid
WAS77156Medicare UPIN