Healthcare Provider Details

I. General information

NPI: 1831812387
Provider Name (Legal Business Name): KENNEDY ST. CLARE RUTLEDGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 10/05/2024
Certification Date: 10/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SILVERSIDE RD STE 2
WILMINGTON DE
19810-3724
US

IV. Provider business mailing address

2700 SILVERSIDE RD STE 2
WILMINGTON DE
19810-3724
US

V. Phone/Fax

Practice location:
  • Phone: 302-478-8421
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0011805
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: