Provider Demographics
NPI:1194039289
Name:TUCKER, CARRIE S (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:S
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N 4TH ST
Mailing Address - Street 2:PO BOX 19670
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5238
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-747-1351
Practice Address - Street 1:520 N 4TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5238
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-747-1351
Is Sole Proprietor?:No
Enumeration Date:2010-07-30
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL318788279001Medicaid
IL318788279001Medicaid