Provider Demographics
NPI:1073122198
Name:TUCKER, AMY LEANA
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEANA
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 1:17 COURTLAND RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-3585
Mailing Address - Country:US
Mailing Address - Phone:770-519-4639
Mailing Address - Fax:
Practice Address - Street 1:1618 MARS HILL RD STE A
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-4847
Practice Address - Country:US
Practice Address - Phone:706-705-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA216188163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse