Provider Demographics
NPI:1437242393
Name:TUCKER, CAROL A (NP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:A
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN RN CDE APRN NP
Mailing Address - Street 1:1200 E MICHIGAN AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1800
Mailing Address - Country:US
Mailing Address - Phone:517-364-5955
Mailing Address - Fax:517-364-5959
Practice Address - Street 1:1200 E MICHIGAN AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1800
Practice Address - Country:US
Practice Address - Phone:517-364-5955
Practice Address - Fax:517-364-5959
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704124272363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4910775Medicaid
MIN50760003Medicare ID - Type UnspecifiedUPIN Q73397