Provider Demographics
NPI:1407521313
Name:RUCKER, KRISTY
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 S EXTENSION RD APT 1146
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4927
Mailing Address - Country:US
Mailing Address - Phone:480-323-9609
Mailing Address - Fax:
Practice Address - Street 1:1515 S EXTENSION RD APT 1146
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-4927
Practice Address - Country:US
Practice Address - Phone:480-323-9609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician