Provider Demographics
NPI:1932865052
Name:RUCKER, KENESHA LA'SHA
Entity type:Individual
Prefix:
First Name:KENESHA
Middle Name:LA'SHA
Last Name:RUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KENESHA
Other - Middle Name:LA'SHA
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:STNA
Mailing Address - Street 1:PO BOX 341153
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-1153
Mailing Address - Country:US
Mailing Address - Phone:405-821-1103
Mailing Address - Fax:
Practice Address - Street 1:5749 TROY VILLA BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-2647
Practice Address - Country:US
Practice Address - Phone:405-821-1103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH323690820817376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide