Provider Demographics
NPI:1003494741
Name:TUCKER, QUANTISHA DENISE
Entity Type:Individual
Prefix:
First Name:QUANTISHA
Middle Name:DENISE
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 1:557 ASPINWALL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-5487
Mailing Address - Country:US
Mailing Address - Phone:803-722-9388
Mailing Address - Fax:
Practice Address - Street 1:557 ASPINWALL RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-5487
Practice Address - Country:US
Practice Address - Phone:803-722-9388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC60178-59050251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health