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General NPI Number Information
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NPI Number | 1144722422
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Entity Type | Individual
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Provider Name | TATYANA EASTLYN JACK RUDDOCK CNM, ARNP
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Gender | Female
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Dates
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Enumeration Date | 03/02/2018
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Last Update Date | 03/02/2018
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Provider Practice Location Address
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Address Line | 1625 SE 3RD AVE STE 502
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City | FT LAUDERDALE
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State | FL
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Zip | 33316-2521
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Country | US
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Telephone | 954-581-8706
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Fax |
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Provider Business Mailing Address
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Address Line | 7331 NW 35TH ST
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City | LAUDERHILL
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State | FL
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Zip | 33319-4913
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Country | US
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Telephone | 954-529-1607
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367A00000X
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Taxonomy Name | Advanced Practice Midwife
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License Number | 9314525
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License Number State | FL
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