Provider Demographics
NPI:1225384373
Name:TUCKER, CHARNITA NICOLE (STNA)
Entity Type:Individual
Prefix:MISS
First Name:CHARNITA
Middle Name:NICOLE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-3549
Mailing Address - Country:US
Mailing Address - Phone:440-654-2262
Mailing Address - Fax:
Practice Address - Street 1:934 W 14TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-3549
Practice Address - Country:US
Practice Address - Phone:440-654-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400895530409376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide