Provider Demographics
NPI:1598564783
Name:RUCKER, CALLIE ELIZABETH (DPT)
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:ELIZABETH
Last Name:RUCKER
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 WRIGHT AVE UNIT 107
Mailing Address - Street 2:
Mailing Address - City:WAHIAWA
Mailing Address - State:HI
Mailing Address - Zip Code:96786-6112
Mailing Address - Country:US
Mailing Address - Phone:918-863-6191
Mailing Address - Fax:
Practice Address - Street 1:1748 WRIGHT AVE UNIT 107
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786-6112
Practice Address - Country:US
Practice Address - Phone:918-863-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-61142251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic