Provider Demographics
NPI:1487105714
Name:RUDOLPH, LISA (DNP, AGNP-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:DNP, AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 HYATT AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-4314
Mailing Address - Country:US
Mailing Address - Phone:716-697-8342
Mailing Address - Fax:
Practice Address - Street 1:55 WATER ST FL 46
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10041-3211
Practice Address - Country:US
Practice Address - Phone:212-649-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307978-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health