Healthcare Provider Details

I. General information

NPI: 1841463908
Provider Name (Legal Business Name): AMY LANETTE RUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2008
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 LONGHORN DR.
VIOLA AR
72583-0380
US

IV. Provider business mailing address

314 LONGHORN DR.
VIOLA AR
72583-0380
US

V. Phone/Fax

Practice location:
  • Phone: 870-458-2511
  • Fax:
Mailing address:
  • Phone: 870-458-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP1503
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: