Provider Demographics
NPI:1013633619
Name:RUCKER, KALEN (CNM)
Entity Type:Individual
Prefix:MRS
First Name:KALEN
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 THOMAS LN
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-5601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6333
Practice Address - Country:US
Practice Address - Phone:910-353-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X
NC811367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife