Provider Demographics
NPI:1306354931
Name:TUCKER, KRISTY LYNN (HIS)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:LYNN
Other - Last Name:ROSNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4001 N BUTLER AVE STE 5101
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2392
Mailing Address - Country:US
Mailing Address - Phone:505-326-2791
Mailing Address - Fax:
Practice Address - Street 1:4001 N BUTLER AVE STE 5101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2392
Practice Address - Country:US
Practice Address - Phone:505-326-2791
Practice Address - Fax:505-326-2791
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COHAD0000214237600000X
NMHAD0826237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHAD0826OtherHEARING AID DISPENSER
COHAD0000214OtherHEARING AID DISPENSER