Provider Demographics
NPI:1043402555
Name:TUCK, KATIE H (CRNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:H
Last Name:TUCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2470 ROCKY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2833
Mailing Address - Country:US
Mailing Address - Phone:205-978-3336
Mailing Address - Fax:205-503-4915
Practice Address - Street 1:2470 ROCKY RIDGE RD
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2833
Practice Address - Country:US
Practice Address - Phone:205-978-3336
Practice Address - Fax:205-503-4915
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1072378363L00000X
AL1-072378363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051542593OtherBCBS
AL891017461Medicaid
ALZ08424OtherVIVA
ALZ08424OtherVIVA