Provider Demographics
NPI:1871804658
Name:RUDOLPH, LISA DAWN (LPN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DAWN
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 1:2937 ALASKAN AVE
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-6851
Mailing Address - Country:US
Mailing Address - Phone:406-256-7126
Mailing Address - Fax:
Practice Address - Street 1:2937 ALASKAN AVE
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-6851
Practice Address - Country:US
Practice Address - Phone:406-256-7126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT32041164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT32041OtherMONTANA BOARD OF NURSING