Provider Demographics
NPI:1417276627
Name:TUCKER, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
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 1:4 GILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-3402
Mailing Address - Country:US
Mailing Address - Phone:845-353-6524
Mailing Address - Fax:
Practice Address - Street 1:4 GILLIS AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3402
Practice Address - Country:US
Practice Address - Phone:845-353-6524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01000216202164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse