Provider Demographics
NPI:1073700878
Name:TUCKER, NICOLE M (OTR)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:TUCKER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SURREY RDG
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:CO
Mailing Address - Zip Code:80615-8817
Mailing Address - Country:US
Mailing Address - Phone:970-215-4889
Mailing Address - Fax:303-270-2174
Practice Address - Street 1:320 SURREY RDG
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:CO
Practice Address - Zip Code:80615-8817
Practice Address - Country:US
Practice Address - Phone:970-215-4889
Practice Address - Fax:303-270-2174
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1052331225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1052331OtherNATIONAL BOARD CERTIFICAT