Provider Demographics
NPI:1336531243
Name:TUCKER, DAWN RENEE (APRN)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:RENEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CLYDE MORRIS BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8185
Mailing Address - Country:US
Mailing Address - Phone:386-671-0600
Mailing Address - Fax:386-677-9710
Practice Address - Street 1:325 CLYDE MORRIS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-671-0600
Practice Address - Fax:386-677-9710
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9306602363LF0000X
FLAPRN9306602F363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017198900Medicaid
FLP01655870OtherRAILROAD MCR
FLH6569OtherBCBS
FL017198900Medicaid