Provider Demographics
NPI:1225206519
Name:TUCKER, GENNIE LOU (CRNA)
Entity Type:Individual
Prefix:
First Name:GENNIE
Middle Name:LOU
Last Name:TUCKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:GENNIE
Other - Middle Name:L
Other - Last Name:FARRAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:220 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2888
Mailing Address - Country:US
Mailing Address - Phone:540-536-5100
Mailing Address - Fax:540-536-0235
Practice Address - Street 1:1840 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2808
Practice Address - Country:US
Practice Address - Phone:540-536-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-061334367500000X
TNAPN15760367500000X
TNRN181133367500000X
NC280661367500000X
SC20621367500000X
VA0024174010367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00944106OtherRAILROAD MEDICARE
GA003110310AMedicaid
TN1523879Medicaid
TN4295481OtherBLUE CROSS BLUE SHIELD OF TN
SCPENDINGMedicaid
TN4295481OtherBLUE CROSS BLUE SHIELD OF TN
SCPENDINGMedicare PIN