Provider Demographics
NPI:1003540204
Name:RUDOLPH, HANNAH RAE
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:RAE
Last Name:RUDOLPH
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 1:111 NEW HAMPSHIRE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 S STATE ROAD 135 STE 250
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-6223
Practice Address - Country:US
Practice Address - Phone:317-300-1788
Practice Address - Fax:317-743-8103
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004442A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant