Provider Demographics
NPI:1891388674
Name:RUCKER, ALLYSON WHITE (NP)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:WHITE
Last Name:RUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W CYAN VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-1699
Mailing Address - Country:US
Mailing Address - Phone:801-309-0245
Mailing Address - Fax:
Practice Address - Street 1:415 MEDICAL DR STE B200
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4986
Practice Address - Country:US
Practice Address - Phone:801-295-9105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8003670-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care