Provider Demographics
NPI:1073025904
Name:TUCKER, TIAWANA MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:TIAWANA
Middle Name:MICHELLE
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 1:5850 SOUTHERN AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-6552
Mailing Address - Country:US
Mailing Address - Phone:202-710-8815
Mailing Address - Fax:
Practice Address - Street 1:1010 VERMONT AVE NW STE 1003
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-4927
Practice Address - Country:US
Practice Address - Phone:202-827-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
DCHHA8370374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide