Provider Demographics
NPI:1407523111
Name:TUCKER, MARIAN DIANE
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:DIANE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 BROOKSIDE PL
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2869
Mailing Address - Country:US
Mailing Address - Phone:937-620-0121
Mailing Address - Fax:
Practice Address - Street 1:912 BROOKSIDE PL
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2869
Practice Address - Country:US
Practice Address - Phone:937-620-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL21000363124251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health