Provider Demographics
NPI:1053410670
Name:RUDDER, BRANDI SUE (PTA)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:SUE
Last Name:RUDDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:SUE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:TONTITOWN
Mailing Address - State:AR
Mailing Address - Zip Code:72770-0871
Mailing Address - Country:US
Mailing Address - Phone:479-751-3900
Mailing Address - Fax:
Practice Address - Street 1:1112 S 48TH ST
Practice Address - Street 2:STE B
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-5848
Practice Address - Country:US
Practice Address - Phone:479-751-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant