Provider Demographics
NPI:1376980482
Name:TUCKER, MALLORY CONWAY (RN, MSN, NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:CONWAY
Last Name:TUCKER
Suffix:
Gender:F
Credentials:RN, MSN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DOCTORS DR
Mailing Address - Street 2:SUITE N
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1589
Mailing Address - Country:US
Mailing Address - Phone:252-559-2200
Mailing Address - Fax:252-522-9778
Practice Address - Street 1:101 BETHESDA DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7298
Practice Address - Country:US
Practice Address - Phone:252-758-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF0513226363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD052AMedicare PIN