=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043452972
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA B RUDOLPH CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2009
-----------------------------------------------------
Last Update Date | 04/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 W GROVE ST STE 120
-----------------------------------------------------
City | KAUFMAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75142-1883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-932-1319
-----------------------------------------------------
Fax | 972-932-1396
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4901 VETERANS MEMORIAL BLVD
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70006-5210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-887-1133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | AP05388
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 162093
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------