Provider Demographics
NPI:1417552829
Name:TUCKER BOREN, ALEXANDRA (DPT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:TUCKER BOREN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-1637
Mailing Address - Country:US
Mailing Address - Phone:615-988-4552
Mailing Address - Fax:615-382-0501
Practice Address - Street 1:514 S BROWN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-2937
Practice Address - Country:US
Practice Address - Phone:615-988-4552
Practice Address - Fax:615-382-0501
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN129572251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN12957OtherSTATE LICENSE