Basic Information
Provider Information | |||||||||
NPI: | 1174011316 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUCANO | ||||||||
FirstName: | DEANNA | ||||||||
MiddleName: | MARGARET | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DENIS | ||||||||
OtherFirstName: | DEANNA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2500 NILES AVE. | ||||||||
Address2: |   | ||||||||
City: | ST. JOSEPH | ||||||||
State: | MI | ||||||||
PostalCode: | 49085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2699838282 | ||||||||
FaxNumber: | 2699854535 | ||||||||
Practice Location | |||||||||
Address1: | 3950 HOLLYWOOD RD STE 270 | ||||||||
Address2: |   | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MI | ||||||||
PostalCode: | 490859158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2699830500 | ||||||||
FaxNumber: | 2694292240 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2018 | ||||||||
LastUpdateDate: | 10/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71009611A | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 4704261973 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.