MEDICARE: MISS CARLY PAIGE RUDNICK MS, LCGC

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	170300000X	Genetic Counselor (M.S.)	GC002008	CA

General Provider Information

NPI Number	:	1770455206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CARLY PAIGE RUDNICK MS, LCGC

Provider Business Mailing Address
First Line	:	1022 EL CAMINO DR APT B
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-5555
Country	:	US
Telephone Number	:	678-640-5403
Fax Number	:

Provider Business Practice Location Address
First Line	:	1022 EL CAMINO DR APT B
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-5555
Country	:	US
Telephone Number	:	678-640-5403
Fax Number	:

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

Provider Enumeration Date	:	09/23/2025
Last Update Date	:	09/23/2025

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