Healthcare Provider Details

I. General information

NPI: 1346078052
Provider Name (Legal Business Name): TIARA DOLORES RUDZINSKI AG-CNS BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MICHIGAN ST NW STE 424
GRAND RAPIDS MI
49503-3799
US

IV. Provider business mailing address

109 MICHIGAN ST NW STE 424
GRAND RAPIDS MI
49503-3799
US

V. Phone/Fax

Practice location:
  • Phone: 616-200-8435
  • Fax: 616-639-1319
Mailing address:
  • Phone: 616-200-8435
  • Fax: 616-639-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number4704345043
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: