Provider Demographics
NPI:1487005039
Name:RUCKER, GLENDA FAYE
Entity Type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:FAYE
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:GLENDA
Other - Middle Name:FAYE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14309 ROCKDALE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2518
Mailing Address - Country:US
Mailing Address - Phone:313-534-1495
Mailing Address - Fax:
Practice Address - Street 1:14309 ROCKDALE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2518
Practice Address - Country:US
Practice Address - Phone:313-534-1495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other