Healthcare Provider Details

I. General information

NPI: 1285774844
Provider Name (Legal Business Name): GUY H. J. RUDDICK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 S NATIONAL AVE
SPRINGFIELD MO
65807-7304
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-5666
  • Fax: 417-890-4174
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2000161005
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: