Provider Demographics
NPI:1174828180
Name:TUCKER, DEADRA RENEA (APN)
Entity Type:Individual
Prefix:
First Name:DEADRA
Middle Name:RENEA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 FANNING HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:TN
Mailing Address - Zip Code:37306-2722
Mailing Address - Country:US
Mailing Address - Phone:931-759-4949
Mailing Address - Fax:
Practice Address - Street 1:1802 N JACKSON ST
Practice Address - Street 2:SUITE 8
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8218
Practice Address - Country:US
Practice Address - Phone:931-455-4520
Practice Address - Fax:931-455-4633
Is Sole Proprietor?:No
Enumeration Date:2011-01-22
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15536363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily