Provider Demographics
NPI:1538565130
Name:RUCKER, BRANDON (LPN)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:RUCKER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24451 LAKE SHORE BLVD APT 1817
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1264
Mailing Address - Country:US
Mailing Address - Phone:614-824-7590
Mailing Address - Fax:
Practice Address - Street 1:24451 LAKE SHORE BLVD APT 1817
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-1264
Practice Address - Country:US
Practice Address - Phone:614-824-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-08
Last Update Date:2014-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.156457-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse