Healthcare Provider Details

I. General information

NPI: 1962632893
Provider Name (Legal Business Name): LEEWHITNEY MEADOWS RUDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 BROADWAY ST
PADUCAH KY
42001-0713
US

IV. Provider business mailing address

425 BROADWAY ST
PADUCAH KY
42001-0713
US

V. Phone/Fax

Practice location:
  • Phone: 270-444-3620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: