Provider Demographics
NPI:1366172520
Name:TUCKER, LANZANDRA DESHA
Entity type:Individual
Prefix:
First Name:LANZANDRA
Middle Name:DESHA
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 1:108 RAMONA DR SW
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-4456
Mailing Address - Country:US
Mailing Address - Phone:478-251-0166
Mailing Address - Fax:
Practice Address - Street 1:108 RAMONA DR SW
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-4456
Practice Address - Country:US
Practice Address - Phone:478-251-0166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy