Provider Demographics
NPI:1316023807
Name:RUDERMAN, MICHELE LEIGH (RD)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:LEIGH
Last Name:RUDERMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 PROUT LANE
Mailing Address - Street 2:
Mailing Address - City:STORMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12582
Mailing Address - Country:US
Mailing Address - Phone:914-715-3002
Mailing Address - Fax:484-933-3002
Practice Address - Street 1:342 DOWNING DRIVE
Practice Address - Street 2:
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598
Practice Address - Country:US
Practice Address - Phone:914-715-3002
Practice Address - Fax:484-933-3002
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY54851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL916683OtherRD
NY54851OtherCDN