Healthcare Provider Details

I. General information

NPI: 1083606156
Provider Name (Legal Business Name): DEANNA N. RUDDELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16101 CANTRELL RD STE 104
LITTLE ROCK AR
72223-4578
US

IV. Provider business mailing address

16101 CANTRELL RD STE 104
LITTLE ROCK AR
72223-4578
US

V. Phone/Fax

Practice location:
  • Phone: 501-425-0322
  • Fax:
Mailing address:
  • Phone: 501-425-0322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberN8430
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: