Provider Demographics
NPI:1245373463
Name:RUKENBROD, MARY ELIZABETH SALE (FNP)
Entity type:Individual
Prefix:
First Name:MARY ELIZABETH
Middle Name:SALE
Last Name:RUKENBROD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 W ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-2820
Mailing Address - Country:US
Mailing Address - Phone:704-296-4800
Mailing Address - Fax:704-296-4887
Practice Address - Street 1:1224 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2820
Practice Address - Country:US
Practice Address - Phone:704-296-4800
Practice Address - Fax:704-296-4887
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172789163W00000X, 363L00000X
NC201952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MR1184819OtherDEA