Basic Information
| Provider Information | |||||||||
| NPI: | 1285190504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUCKER | ||||||||
| FirstName: | KEYUANA | ||||||||
| MiddleName: | TIERA | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6990 BOXBOROUGH CV | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381198783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015626476 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Practice Location | |||||||||
| Address1: | 6990 BOXBOROUGH CV | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381198783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015626476 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2019 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 2621 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.