Provider Demographics
NPI:1336328749
Name:TUCKER, STEPHANIE BETH (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:BETH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:BETH
Other - Last Name:EVITTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN
Mailing Address - Street 1:425 LEWIS HARGETT CIR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3590
Mailing Address - Country:US
Mailing Address - Phone:859-268-1030
Mailing Address - Fax:859-269-4120
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1653
Practice Address - Country:US
Practice Address - Phone:270-825-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2018-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1096558367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100020780Medicaid
KY1096558OtherLICENSE
KY1096558OtherLICENSE
KYP00442736Medicare PIN