Healthcare Provider Details

I. General information

NPI: 1487344644
Provider Name (Legal Business Name): OLIVIA RUDER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86TH & MAIN
SELLS AZ
85634
US

IV. Provider business mailing address

86TH & MAIN
SELLS AZ
85634
US

V. Phone/Fax

Practice location:
  • Phone: 520-383-7330
  • Fax:
Mailing address:
  • Phone: 520-383-7330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number287771
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: