Provider Demographics
NPI:1245631894
Name:RUCKER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3583 ALASKA AVE APT D9
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-2546
Mailing Address - Country:US
Mailing Address - Phone:513-401-5006
Mailing Address - Fax:
Practice Address - Street 1:3583 ALASKA AVE APT D9
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-2546
Practice Address - Country:US
Practice Address - Phone:513-401-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH373366980494372600000X, 3747A0650X, 3747P1801X, 374U00000X, 376J00000X, 376K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0069Medicaid
0000000069Medicare PIN
OH0000000069Medicare NSC
OH0000000069Medicare Oscar/Certification
OH0000000069Medicare UPIN