Healthcare Provider Details

I. General information

NPI: 1831057819
Provider Name (Legal Business Name): SHELBY DIANE RUDDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 SE BAYBERRY LN
LEES SUMMIT MO
64063-4301
US

IV. Provider business mailing address

656 SE BAYBERRY LN
LEES SUMMIT MO
64063-4301
US

V. Phone/Fax

Practice location:
  • Phone: 816-281-7558
  • Fax:
Mailing address:
  • Phone: 816-281-7558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2019023072
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-320792
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: