Healthcare Provider Details

I. General information

NPI: 1487497582
Provider Name (Legal Business Name): KRISTA MARLEE RUDD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 82ND PKWY
MYRTLE BEACH SC
29572-4607
US

IV. Provider business mailing address

7035 SKIFF LN UNIT 302
MYRTLE BEACH SC
29572-4536
US

V. Phone/Fax

Practice location:
  • Phone: 843-692-1000
  • Fax:
Mailing address:
  • Phone: 843-712-6273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28894
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: