Provider Demographics
NPI:1184223836
Name:TUCKER, TINA RENEE
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:RENEE
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 1:108 RESERVE CIR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-9311
Mailing Address - Country:US
Mailing Address - Phone:440-315-1932
Mailing Address - Fax:
Practice Address - Street 1:108 RESERVE CIR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:OH
Practice Address - Zip Code:44090-9311
Practice Address - Country:US
Practice Address - Phone:440-315-1932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4702361Medicaid