Provider Demographics
NPI:1386901486
Name:TUCKER, BECKY CONLEY (NP)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:CONLEY
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 COMMUNITY RD
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427-7711
Mailing Address - Country:US
Mailing Address - Phone:912-654-9170
Mailing Address - Fax:337-262-9736
Practice Address - Street 1:1004 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-7711
Practice Address - Country:US
Practice Address - Phone:912-654-9170
Practice Address - Fax:337-262-9736
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN137050363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health