Provider Demographics
NPI:1306400601
Name:TUCKER, KRISTIN SHARP
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SHARP
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 1:604 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-3060
Mailing Address - Country:US
Mailing Address - Phone:229-333-0277
Mailing Address - Fax:229-241-1608
Practice Address - Street 1:604 E PARK AVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-3060
Practice Address - Country:US
Practice Address - Phone:229-333-0277
Practice Address - Fax:229-241-1608
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195188363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily