Provider Demographics
NPI:1447045414
Name:RUCKER, KELLY MARIE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:RUCKER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 OLD VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:RICH CREEK
Mailing Address - State:VA
Mailing Address - Zip Code:24147-9637
Mailing Address - Country:US
Mailing Address - Phone:540-599-2909
Mailing Address - Fax:
Practice Address - Street 1:159 HARTLEY WAY
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-2471
Practice Address - Country:US
Practice Address - Phone:540-921-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty