Basic Information
| Provider Information | |||||||||
| NPI: | 1174183578 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDDELL | ||||||||
| FirstName: | KERRI | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1387 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838351387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084150299 | ||||||||
| FaxNumber: | 2086252070 | ||||||||
| Practice Location | |||||||||
| Address1: | 16760 N HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | RATHDRUM | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838588715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086875627 | ||||||||
| FaxNumber: | 8448073782 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2019 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 61858 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | NP61858 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.