| Doctor Name: | MRS. CAROLE ANN DERUCKI |
| NPI Number: | 1205809225 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CN-P |
| License Number: | 71002723A |
| Business Practice Address: | 611 E Douglas Rd Suite 305 Mishawaka, IN - 465451464 |
| Business Phone Number: | 5744706700 |
| Business Fax Number: | 5743350760 |
| Mailing Address: | Po Box 6309, SOUTH BEND |
| State: | IN |
| Postal Code: | 466606309 |
| Phone Number: | 5744726700 |
| Fax Number: | 5743350760 |
| NPI Enumeration Date: | 02/09/2006 |
| NPI Last Update Date: | 10/07/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | 71002723A |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | IN |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |