Provider Demographics
NPI:1194482638
Name:RUDDLE, KAYA KALEOLANI (MAS)
Entity type:Individual
Prefix:
First Name:KAYA
Middle Name:KALEOLANI
Last Name:RUDDLE
Suffix:
Gender:F
Credentials:MAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 CABINET GORGE RD
Mailing Address - Street 2:
Mailing Address - City:CLARK FORK
Mailing Address - State:ID
Mailing Address - Zip Code:83811-7002
Mailing Address - Country:US
Mailing Address - Phone:208-304-2535
Mailing Address - Fax:
Practice Address - Street 1:770 CABINET GORGE RD
Practice Address - Street 2:
Practice Address - City:CLARK FORK
Practice Address - State:ID
Practice Address - Zip Code:83811-7002
Practice Address - Country:US
Practice Address - Phone:208-304-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3798225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist