Provider Demographics
NPI:1215404991
Name:TUCKER, KOURTNEY L
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:L
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 1:1987 COUNTY ROAD 4152
Mailing Address - Street 2:
Mailing Address - City:SIMMS
Mailing Address - State:TX
Mailing Address - Zip Code:75574-3525
Mailing Address - Country:US
Mailing Address - Phone:903-276-0635
Mailing Address - Fax:
Practice Address - Street 1:1987 COUNTY ROAD 4152
Practice Address - Street 2:
Practice Address - City:SIMMS
Practice Address - State:TX
Practice Address - Zip Code:75574-3525
Practice Address - Country:US
Practice Address - Phone:903-276-0635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX698937163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health