Provider Demographics
NPI:1033994504
Name:RUCKER, CHRYSTAL LEVERN (RN)
Entity Type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:LEVERN
Last Name:RUCKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MISTY LN
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:SC
Mailing Address - Zip Code:29627-9576
Mailing Address - Country:US
Mailing Address - Phone:864-940-1250
Mailing Address - Fax:
Practice Address - Street 1:10 ENTERPRISE BLVD STE 109
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3534
Practice Address - Country:US
Practice Address - Phone:864-458-7141
Practice Address - Fax:864-676-9116
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC103315163W00000X
SC27927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse