Healthcare Provider Details

I. General information

NPI: 1801053830
Provider Name (Legal Business Name): ERIN RUUD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERIN SCOTT NP

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR STE 320
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DRIVE SUITE 320
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 314-704-2201
  • Fax:
Mailing address:
  • Phone: 314-704-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209007075
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: