Provider Demographics
NPI:1346324431
Name:TUCKER, POLLY T (FNP)
Entity Type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:T
Last Name:TUCKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 LAUDERDALE DRIVE
Mailing Address - Street 2:MINUTECLINIC
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7612
Mailing Address - Country:US
Mailing Address - Phone:804-360-7598
Mailing Address - Fax:804-364-0928
Practice Address - Street 1:3001 LAUDERDALE DRIVE
Practice Address - Street 2:MINUTECLINIC
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-7612
Practice Address - Country:US
Practice Address - Phone:804-360-7598
Practice Address - Fax:804-364-0928
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024067141363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007782217Medicaid
VAP62984Medicare UPIN
VA500001115Medicare ID - Type UnspecifiedC03684