Healthcare Provider Details

I. General information

NPI: 1578337770
Provider Name (Legal Business Name): NICOLETTA VICTORIA RUDI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2073 KLOCKNER RD
HAMILTON NJ
08690-3414
US

IV. Provider business mailing address

1984 BIRCHWOOD PARK DR N
CHERRY HILL NJ
08003-1029
US

V. Phone/Fax

Practice location:
  • Phone: 609-584-1212
  • Fax: 609-584-0103
Mailing address:
  • Phone: 609-634-0487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA065214
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00816100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: