Healthcare Provider Details

I. General information

NPI: 1285838581
Provider Name (Legal Business Name): LISA RUDOLPH CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NORTH LEE
OKLAHOMA CITY OK
73101-1036
US

IV. Provider business mailing address

2105 DEL SIMMONS DR
EDMOND OK
73003-2411
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-6368
  • Fax:
Mailing address:
  • Phone: 405-315-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number38393
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: