Healthcare Provider Details

I. General information

NPI: 1104147032
Provider Name (Legal Business Name): LORI ASHLOCK-RUDA FNP-C LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

800 STATE HIGHWAY 248 BLDG III UL
BRANSON MO
65616-3721
US

IV. Provider business mailing address

800 STATE HIGHWAY 248 BLDG III UL
BRANSON MO
65616-3721
US

V. Phone/Fax

Practice location:
  • Phone: 417-336-3627
  • Fax:
Mailing address:
  • Phone: 417-336-3627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number136833
License Number StateMO

VIII. Authorized Official

Name: LORI ASHLOCK-RUDA
Title or Position: OWNER
Credential: FNP-C
Phone: 417-336-3627