Provider Demographics
NPI:1346223047
Name:TUCKER, MARY KAY (RN BSN MPH CPNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY KAY
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:RN BSN MPH CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 IVYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5050
Mailing Address - Country:US
Mailing Address - Phone:336-659-0558
Mailing Address - Fax:
Practice Address - Street 1:8 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-6768
Practice Address - Country:US
Practice Address - Phone:336-249-4911
Practice Address - Fax:336-249-1782
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC73417363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
S90621Medicare UPIN