Provider Demographics
NPI:1306663562
Name:RUCKER, TINA M (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:RUCKER
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25201 S CHENNAULT AVE
Mailing Address - Street 2:
Mailing Address - City:MONEE
Mailing Address - State:IL
Mailing Address - Zip Code:60449-9020
Mailing Address - Country:US
Mailing Address - Phone:630-376-8810
Mailing Address - Fax:
Practice Address - Street 1:25201 S CHENNAULT AVE
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-9020
Practice Address - Country:US
Practice Address - Phone:630-376-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041397757207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine