Provider Demographics
NPI:1215334016
Name:TUCKER, TERESA WALLACE (RN)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:WALLACE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:ALICIA
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2659 PIPER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3458
Mailing Address - Country:US
Mailing Address - Phone:757-561-8878
Mailing Address - Fax:
Practice Address - Street 1:2659 PIPER HILLS DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-3458
Practice Address - Country:US
Practice Address - Phone:757-561-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014032763163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse