MEDICARE: LISA DAWN RUDOLPH 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	32041	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32041	OTHER	MT	MONTANA BOARD OF NURSING

General Provider Information

NPI Number	:	1871804658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DAWN RUDOLPH LPN

Provider Business Mailing Address
First Line	:	2937 ALASKAN AVE
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59101-6851
Country	:	US
Telephone Number	:	406-256-7126
Fax Number	:

Provider Business Practice Location Address
First Line	:	2937 ALASKAN AVE
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59101-6851
Country	:	US
Telephone Number	:	406-256-7126
Fax Number	:

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

Provider Enumeration Date	:	06/28/2010
Last Update Date	:	06/28/2010

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