Provider Demographics
NPI:1174183578
Name:RUDDELL, KERRI (NP)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:RUDDELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3665 W EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9018
Mailing Address - Country:US
Mailing Address - Phone:208-790-5191
Mailing Address - Fax:
Practice Address - Street 1:502 E AMENDE DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:WA
Practice Address - Zip Code:99159-7003
Practice Address - Country:US
Practice Address - Phone:509-982-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP61858363LF0000X
ID61858363LF0000X
WAAP61469089363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily