Healthcare Provider Details

I. General information

NPI: 1881508646
Provider Name (Legal Business Name): TAMMIE KAYVONE RUDOLPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 AVENUE E
NORFOLK VA
23513-1701
US

IV. Provider business mailing address

953 AVENUE E
NORFOLK VA
23513-1701
US

V. Phone/Fax

Practice location:
  • Phone: 757-735-4755
  • Fax:
Mailing address:
  • Phone: 757-735-4755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0001212734
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: