Healthcare Provider Details

I. General information

NPI: 1588422455
Provider Name (Legal Business Name): NICOLE RUGH LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE SHRUBB

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 CAMPUS DR
BRADFORD PA
16701-1982
US

IV. Provider business mailing address

110 CAMPUS DR
BRADFORD PA
16701-1982
US

V. Phone/Fax

Practice location:
  • Phone: 814-362-6536
  • Fax: 814-817-2115
Mailing address:
  • Phone: 814-362-6536
  • Fax: 814-817-2115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW138087
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: