Healthcare Provider Details

I. General information

NPI: 1174055800
Provider Name (Legal Business Name): DOUGLAS RUTLEDGE APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ROUTE 45
SALEM NJ
08079-2000
US

IV. Provider business mailing address

19 KAYLAS WAY
MULLICA HILL NJ
08062-2101
US

V. Phone/Fax

Practice location:
  • Phone: 856-887-3005
  • Fax: 856-759-4035
Mailing address:
  • Phone: 856-340-5766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00716600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: