Provider Demographics
NPI:1104169473
Name:TUCKER, KENDRA MAE
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:MAE
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 1:514 CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-2413
Mailing Address - Country:US
Mailing Address - Phone:425-422-1867
Mailing Address - Fax:
Practice Address - Street 1:120 AVENUE A
Practice Address - Street 2:STE. C
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2961
Practice Address - Country:US
Practice Address - Phone:360-563-0629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60109855172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist