Provider Demographics
NPI:1225578198
Name:TUCKER, AUTUMN RAE (CNP)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:RAE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 S MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:SD
Mailing Address - Zip Code:57555
Mailing Address - Country:US
Mailing Address - Phone:605-856-2295
Mailing Address - Fax:
Practice Address - Street 1:161 S, MAIN STREET
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:SD
Practice Address - Zip Code:57555
Practice Address - Country:US
Practice Address - Phone:605-856-2295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001196363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health