Healthcare Provider Details

I. General information

NPI: 1629700349
Provider Name (Legal Business Name): LISA PAULA RUDD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 03/11/2024
Certification Date: 03/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 N CHURCH ST STE 200
GREENSBORO NC
27401-1040
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-379-9445
  • Fax:
Mailing address:
  • Phone: 336-716-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5016456
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5016456
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: