Healthcare Provider Details

I. General information

NPI: 1326561135
Provider Name (Legal Business Name): VIRGINIA DIANE RUDOLF AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIRGINIA DIANE DUCKWORTH AGACNP-BC

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3290 DAUPHIN ST STE 301
MOBILE AL
36606-4052
US

IV. Provider business mailing address

PO BOX 21595
BELFAST ME
04915-4112
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-5930
  • Fax: 251-660-5931
Mailing address:
  • Phone: 251-300-5941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number3-000465
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number902189
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3-000465
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: