Provider Demographics
NPI:1386775641
Name:TUCKER, MARY W (APRN, BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:W
Last Name:TUCKER
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5629
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:116 CHANTILLY LANE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37803
Practice Address - Country:US
Practice Address - Phone:865-273-1616
Practice Address - Fax:865-273-1645
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000010443363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNAPN0000010443OtherLICENSE
TN3341063Medicaid
TN3341063Medicaid