MEDICARE: TIARA DOLORES RUDZINSKI AG-CNS BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364S00000X	Clinical Nurse Specialist	4704345043	MI

General Provider Information

NPI Number	:	1346078052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIARA DOLORES RUDZINSKI AG-CNS BC

Provider Business Mailing Address
First Line	:	1355 BRISTOL AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-2902
Country	:	US
Telephone Number	:	219-477-8854
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 VAN BUREN ST
Second Line	:
City	:	HUDSONVILLE
State	:	MI
Zip	:	49426-1097
Country	:	US
Telephone Number	:	616-669-1520
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2024
Last Update Date	:	08/15/2024

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