Provider Demographics
NPI:1346078052
Name:RUDZINSKI, TIARA DOLORES (AG-CNS BC)
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:DOLORES
Last Name:RUDZINSKI
Suffix:
Gender:F
Credentials:AG-CNS BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 BRISTOL AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2902
Mailing Address - Country:US
Mailing Address - Phone:219-477-8854
Mailing Address - Fax:
Practice Address - Street 1:3650 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1097
Practice Address - Country:US
Practice Address - Phone:616-669-1520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-24
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704345043364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist