MEDICARE: DAEJUANAE RUTLAND LPN

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	164W00000X	Licensed Practical Nurse	LPN.188044	OH

General Provider Information

NPI Number	:	1598611139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAEJUANAE RUTLAND LPN

Provider Business Mailing Address
First Line	:	11361 N 99TH AVE STE 402
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-5459
Country	:	US
Telephone Number	:	602-650-1212
Fax Number	:

Provider Business Practice Location Address
First Line	:	465 HARMON AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43223
Country	:	US
Telephone Number	:	614-222-3737
Fax Number	:	614-358-4201

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

Provider Enumeration Date	:	03/06/2026
Last Update Date	:	03/06/2026

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