Provider Demographics
NPI:1245825157
Name:FADAEL-CORREA, RUDGIE (CM)
Entity type:Individual
Prefix:
First Name:RUDGIE
Middle Name:
Last Name:FADAEL-CORREA
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 E 32ND ST APT A10
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2600
Mailing Address - Country:US
Mailing Address - Phone:718-909-0205
Mailing Address - Fax:
Practice Address - Street 1:585 E 32ND ST APT A10
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2600
Practice Address - Country:US
Practice Address - Phone:718-909-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF002053367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife