Healthcare Provider Details

I. General information

NPI: 1235428053
Provider Name (Legal Business Name): KATIE LYNN RUDY-TOMCZAK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE LYNN RUDY FNP

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SUMMIT AVE
MONTVALE NJ
07645-1523
US

IV. Provider business mailing address

155 CRYSTAL RUN RD
MIDDLETOWN NY
10941-4028
US

V. Phone/Fax

Practice location:
  • Phone: 201-775-7000
  • Fax:
Mailing address:
  • Phone: 845-703-6999
  • Fax: 845-703-6297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00947900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF336499
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: