Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | 104409571 | MO |
NPI | 1053834671 |
---|---|
Provider Name | Mindy Rudolf |
First Address | Saint Louis, MO 63110-1002 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2017 |
Last Update Date | 25/07/2017 |