Provider Demographics
NPI:1396111613
Name:RUDD, LAUREL
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:RUDD
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 1:6397 WELLS DR
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1522
Mailing Address - Country:US
Mailing Address - Phone:315-433-2391
Mailing Address - Fax:
Practice Address - Street 1:6575 KIRKVILLE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9809
Practice Address - Country:US
Practice Address - Phone:315-701-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY544906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist