Healthcare Provider Details

I. General information

NPI: 1770876302
Provider Name (Legal Business Name): STINA JENNIFER RUDDELL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 5TH ST SE
CAIRO GA
39828-3139
US

IV. Provider business mailing address

900 CAIRO RD
THOMASVILLE GA
31792-4255
US

V. Phone/Fax

Practice location:
  • Phone: 229-377-1100
  • Fax:
Mailing address:
  • Phone: 229-227-5158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number006097
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: