Provider Demographics
NPI:1285406264
Name:RUCKER, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
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 1:5021 HEDGEBROOK LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7073
Mailing Address - Country:US
Mailing Address - Phone:502-541-8285
Mailing Address - Fax:
Practice Address - Street 1:5021 HEDGEBROOK LN
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7073
Practice Address - Country:US
Practice Address - Phone:502-541-8285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC374J00000X
NC1003584525405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional
No374J00000XNursing Service Related ProvidersDoula