Provider Demographics
NPI:1205899473
Name:RUECKERT, KELLI JO (LAT, ATC)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:RUECKERT
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:BLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 80
Mailing Address - Street 2:
Mailing Address - City:OSSIAN
Mailing Address - State:IA
Mailing Address - Zip Code:52161-0080
Mailing Address - Country:US
Mailing Address - Phone:563-532-8900
Mailing Address - Fax:563-387-3021
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:563-387-3031
Practice Address - Fax:563-387-3021
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer