Basic Information
| Provider Information | |||||||||
| NPI: | 1396086591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDOLPH | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | JAYNE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25317 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336225317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135332908 | ||||||||
| FaxNumber: | 8133156924 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 6TH AVE S STE 350 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274560080 | ||||||||
| FaxNumber: | 7274560089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2013 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN9432470 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | ARNP9432470 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.