Healthcare Provider Details

I. General information

NPI: 1336125111
Provider Name (Legal Business Name): BEVERLY A RUTLEDGE WHCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W 36TH ST SUITE 205
ST LOUIS PARK MN
55416-2758
US

IV. Provider business mailing address

5000 W 36TH ST SUITE 205
ST LOUIS PARK MN
55416-2758
US

V. Phone/Fax

Practice location:
  • Phone: 952-807-0415
  • Fax: 952-236-6461
Mailing address:
  • Phone: 952-807-0415
  • Fax: 952-236-6461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRUT104299027
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: