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General NPI Number Information
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NPI Number | 1578320917
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Entity Type | Individual
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Provider Name | SAMANTHA RUDER FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 03/04/2024
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Last Update Date | 03/12/2024
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Provider Practice Location Address
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Address Line | 2490 CENTRAL AVE
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City | LAKE STATION
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State | IN
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Zip | 46405-2122
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Country | US
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Telephone | 811-221-9763
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Fax |
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Provider Business Mailing Address
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Address Line | 3712 LAKE HURON DR APT 205
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City | VALPARAISO
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State | IN
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Zip | 46383-6746
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Country | US
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Telephone | 219-671-4927
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 71014964A
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License Number State | IN
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