MEDICARE: HEATHER RUDALAVAGE RD, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DN004094	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1265734917	OTHER	PA	NPI

General Provider Information

NPI Number	:	1265734917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER RUDALAVAGE RD, LDN

Provider Business Mailing Address
First Line	:	1023 HAWTHORNE LN
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-1736
Country	:	US
Telephone Number	:	215-696-3238
Fax Number	:

Provider Business Practice Location Address
First Line	:	1023 HAWTHORNE LN
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-1736
Country	:	US
Telephone Number	:	215-643-3572
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2010
Last Update Date	:	02/01/2019

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