Healthcare Provider Details

I. General information

NPI: 1346578853
Provider Name (Legal Business Name): MARYBETH ANDREA RUDISILE RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 11/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4437 INNSBRUCK RDG
MEDFORD OR
97504-9058
US

IV. Provider business mailing address

4437 INNSBRUCK RDG
MEDFORD OR
97504-9058
US

V. Phone/Fax

Practice location:
  • Phone: 541-227-3180
  • Fax:
Mailing address:
  • Phone: 541-227-3180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200842425RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number200842425RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: