=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104646033
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDRIA CHRISTINA RUDDY NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2024
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 NORTHERN BLVD STE 220
-----------------------------------------------------
City | GREENVALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11548-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-302-8530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2330 SMITH LN
-----------------------------------------------------
City | SEAFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11783-3237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-291-0919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | F311840
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------