Healthcare Provider Details

I. General information

NPI: 1124175435
Provider Name (Legal Business Name): MARILYNN ELIZABETH RUDOLPH RRT, AE-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14500 99TH AVE N
MAPLE GROVE MN
55369-4730
US

IV. Provider business mailing address

10569 QUINCY BLVD NE
BLAINE MN
55434-2721
US

V. Phone/Fax

Practice location:
  • Phone: 763-898-1117
  • Fax: 763-898-1061
Mailing address:
  • Phone: 763-717-1564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279P1006X
TaxonomyPulmonary Function Technologist Registered Respiratory Therapist
License Number1275
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: