Healthcare Provider Details

I. General information

NPI: 1316461742
Provider Name (Legal Business Name): RACHEL FUDGE RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 RIDINGS AVE
MOLALLA OR
97038-9201
US

IV. Provider business mailing address

12274 SW PALERMO ST
WILSONVILLE OR
97070-7244
US

V. Phone/Fax

Practice location:
  • Phone: 503-829-5591
  • Fax:
Mailing address:
  • Phone: 503-329-8051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201703355RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: