1356605950 NPI number — ELLEN JANE RUDY CPCP

Table of content: ELLEN JANE RUDY CPCP (NPI 1356605950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356605950 NPI number — ELLEN JANE RUDY CPCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDY
Provider First Name:
ELLEN
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPCP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RUDY
Provider Other First Name:
PENNY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CPCP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1356605950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8115 74TH PL NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYSVILLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98270-7764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-418-4115
Provider Business Mailing Address Fax Number:
360-651-7600

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3204 SMOKEY POINT DR
Provider Second Line Business Practice Location Address:
SUITE # 201
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98223-8476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-657-7040
Provider Business Practice Location Address Fax Number:
360-651-7600
Provider Enumeration Date:
06/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 246Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0001389 . This is a "DEPT OF LICENSING- LICENSED ARTIST OPERATOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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