Healthcare Provider Details

I. General information

NPI: 1851225585
Provider Name (Legal Business Name): SARA ANN RUDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3175 SIENNA DR S STE 103
FARGO ND
58104-8910
US

IV. Provider business mailing address

3175 SIENNA DR S STE 103
FARGO ND
58104-8910
US

V. Phone/Fax

Practice location:
  • Phone: 701-532-1906
  • Fax: 701-532-1896
Mailing address:
  • Phone: 701-532-1906
  • Fax: 701-532-1896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3122
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: