=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740758937
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARANDA ELYSE RUDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2018
-----------------------------------------------------
Last Update Date | 11/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 E MAIN ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46122-1948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-745-4451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 538 N ENDERLY AVE APT 4
-----------------------------------------------------
City | BROWNSBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46112-1164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-338-8135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 36002206A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------