Provider Demographics
NPI:1366946899
Name:RUTHERFORD, AUDREY KAY (MD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:KAY
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 DEER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-3900
Mailing Address - Country:US
Mailing Address - Phone:817-304-8839
Mailing Address - Fax:
Practice Address - Street 1:1222 W LEGACY CROSSING BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-5560
Practice Address - Country:US
Practice Address - Phone:801-549-0570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12829524-1205207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology