Provider Demographics
NPI:1386048023
Name:TUCKER, SHANNON L (AGPCNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:L
Other - Last Name:STOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:314-996-7940
Mailing Address - Fax:314-996-7945
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:STE 264C
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-996-7940
Practice Address - Fax:314-996-7945
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006019382163W00000X
MO2014036832363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse