Provider Demographics
NPI:1194310359
Name:TUCKER, ALEXIS
Entity type:Individual
Prefix:MISS
First Name:ALEXIS
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 1:2729 MARINER AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-4207
Mailing Address - Country:US
Mailing Address - Phone:330-553-2270
Mailing Address - Fax:
Practice Address - Street 1:2729 MARINER AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-4207
Practice Address - Country:US
Practice Address - Phone:330-553-2270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071615Medicaid