Provider Demographics
NPI:1023387289
Name:RUKLIC, ABIGAIL LYNN (MS, ATC)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:LYNN
Last Name:RUKLIC
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1602
Mailing Address - Country:US
Mailing Address - Phone:708-910-8523
Mailing Address - Fax:
Practice Address - Street 1:4749 LINCOLN MALL DR
Practice Address - Street 2:SUITE 550
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2348
Practice Address - Country:US
Practice Address - Phone:708-283-9765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-17
Last Update Date:2011-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0025072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer