Provider Demographics
NPI:1366078693
Name:TUCKER, KYLA MARIE (NP-C)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:MARIE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 HARTFORD PIKE
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2150
Practice Address - Country:US
Practice Address - Phone:860-412-9190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8802363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily