Healthcare Provider Details

I. General information

NPI: 1609508787
Provider Name (Legal Business Name): REBECCA KUDLATY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 BECKNER RD STE 1600
SANTA FE NM
87507-3641
US

IV. Provider business mailing address

6621 FANNIN ST # MCW1998
HOUSTON TX
77030-2358
US

V. Phone/Fax

Practice location:
  • Phone: 505-772-2000
  • Fax:
Mailing address:
  • Phone: 832-828-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1077309
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number77787
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: