Provider Demographics
NPI:1538616230
Name:RUCKEL, MICHELLE NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:NICOLE
Last Name:RUCKEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:NICOLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1794 OLYMPIC PKWY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1794 OLYMPIC PKWY
Practice Address - Street 2:SUITE 140
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-6387
Practice Address - Country:US
Practice Address - Phone:435-575-0345
Practice Address - Fax:435-575-0346
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7498452-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic