Provider Demographics
NPI:1306568522
Name:RUDOLPH, AMANDA (LPN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5664 FISHER BOWEN BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:WV
Mailing Address - Zip Code:25570-5917
Mailing Address - Country:US
Mailing Address - Phone:740-307-2733
Mailing Address - Fax:
Practice Address - Street 1:5187 US ROUTE 60 STE 13
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2076
Practice Address - Country:US
Practice Address - Phone:304-733-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27095164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse