Healthcare Provider Details

I. General information

NPI: 1093588352
Provider Name (Legal Business Name): HEATHER ANNE KUDIALIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 HOSPITAL DR
MADISON TN
37115-5030
US

IV. Provider business mailing address

315 HOSPITAL DR
MADISON TN
37115-5030
US

V. Phone/Fax

Practice location:
  • Phone: 615-732-7662
  • Fax:
Mailing address:
  • Phone: 615-732-7662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number265175
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: