Provider Demographics
NPI:1063921500
Name:TUCKER, ADIVA
Entity type:Individual
Prefix:
First Name:ADIVA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 PATTERSON GROVES DR
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-6331
Mailing Address - Country:US
Mailing Address - Phone:407-375-5772
Mailing Address - Fax:
Practice Address - Street 1:1975 S JOHN YOUNG PKWY # 203A
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0603
Practice Address - Country:US
Practice Address - Phone:321-236-1540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator