Provider Demographics
NPI:1467217232
Name:RUCKER, NICOLE FORRESTER (FNP-BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:FORRESTER
Last Name:RUCKER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:FORRESTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:165 E WALTON ST
Mailing Address - Street 2:
Mailing Address - City:BACONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31716-7705
Mailing Address - Country:US
Mailing Address - Phone:229-344-4497
Mailing Address - Fax:
Practice Address - Street 1:3131 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6925
Practice Address - Country:US
Practice Address - Phone:229-890-3418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN271979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine