Provider Demographics
NPI:1134539125
Name:RUDOLPH, SHARON DENISE (NP)
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:DENISE
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:D
Other - Last Name:RUFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 25487
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2487
Mailing Address - Country:US
Mailing Address - Phone:941-202-5342
Mailing Address - Fax:855-253-4836
Practice Address - Street 1:4401 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3142
Practice Address - Country:US
Practice Address - Phone:941-357-5550
Practice Address - Fax:941-792-7152
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18646363LF0000X
FL2074876363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0541OtherBCBS
FL015065500Medicaid
FLIE8792Medicare UPIN