Healthcare Provider Details

I. General information

NPI: 1821503111
Provider Name (Legal Business Name): DEMETRIA LAVETTE RUTLEDGE APRN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR STE 125
GRESHAM OR
97030-3794
US

IV. Provider business mailing address

13194 US HIGHWAY 301 S UNIT 228
RIVERVIEW FL
33578-7410
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-8176
  • Fax: 503-665-8176
Mailing address:
  • Phone: 352-807-4857
  • Fax: 352-218-6045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95026940
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9181104
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1160779
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0137529
License Number StateVT
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10010881
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier101700500
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: