Provider Demographics
NPI:1124567557
Name:TUCKER, DIANE C (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:DIANE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:16000 JOHNSTON MEMORIAL DR
Mailing Address - Street 2:SUITE 212A
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24211-7664
Mailing Address - Country:US
Mailing Address - Phone:276-258-3740
Mailing Address - Fax:276-258-3745
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:SUITE 212A
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7664
Practice Address - Country:US
Practice Address - Phone:276-258-3740
Practice Address - Fax:276-258-3745
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174575363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily