Healthcare Provider Details

I. General information

NPI: 1689996274
Provider Name (Legal Business Name): MARY JANE RUDOWSKY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24755 CHAGRIN BLVD 345
BEACHWOOD OH
44122-5682
US

IV. Provider business mailing address

24701 EUCLID AVE 3RD FLOOR
EUCLID OH
44117-1714
US

V. Phone/Fax

Practice location:
  • Phone: 216-464-0778
  • Fax: 216-765-1461
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCOA1145NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN166982
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: