Provider Demographics
NPI:1316628795
Name:TUCKER, KELLYN
Entity type:Individual
Prefix:
First Name:KELLYN
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 1:6961 FLUTE ST SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-5052
Mailing Address - Country:US
Mailing Address - Phone:360-508-5221
Mailing Address - Fax:
Practice Address - Street 1:1534 BISHOP RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7354
Practice Address - Country:US
Practice Address - Phone:360-357-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program