MEDICARE: ELLEN JANE RUDY CPCP

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	246Z00000X	Other Specialist/Technologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0001389	OTHER	WA	DEPT OF LICENSING- LICENSED ARTIST OPERATOR

General Provider Information

NPI Number	:	1356605950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN JANE RUDY CPCP

Provider Business Mailing Address
First Line	:	8115 74TH PL NE
Second Line	:
City	:	MARYSVILLE
State	:	WA
Zip	:	98270-7764
Country	:	US
Telephone Number	:	425-418-4115
Fax Number	:	360-651-7600

Provider Business Practice Location Address
First Line	:	3204 SMOKEY POINT DR
Second Line	:	SUITE # 201
City	:	ARLINGTON
State	:	WA
Zip	:	98223-8476
Country	:	US
Telephone Number	:	360-657-7040
Fax Number	:	360-651-7600

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

Provider Enumeration Date	:	06/28/2012
Last Update Date	:	11/08/2023

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Directions to “ ELLEN JANE RUDY CPCP” Practice Location

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