Provider Demographics
NPI:1316512619
Name:RUCKER, SAVANNAH ELISE (LVN)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:ELISE
Last Name:RUCKER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:ELISE
Other - Last Name:HALTOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:APPLE SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75926-0328
Mailing Address - Country:US
Mailing Address - Phone:936-707-1210
Mailing Address - Fax:
Practice Address - Street 1:3077 HOGG ROAD EXT
Practice Address - Street 2:
Practice Address - City:KENNARD
Practice Address - State:TX
Practice Address - Zip Code:75847
Practice Address - Country:US
Practice Address - Phone:936-707-1210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305576164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse