Provider Demographics
NPI:1760676829
Name:RUCKMAR, MICHELLE MARIE (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:MARIE
Last Name:RUCKMAR
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 SAINT FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-3374
Mailing Address - Country:US
Mailing Address - Phone:952-403-3396
Mailing Address - Fax:
Practice Address - Street 1:1455 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3374
Practice Address - Country:US
Practice Address - Phone:952-403-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered