Provider Demographics
NPI:1487668828
Name:TUCKER-STICKELS, LYDIA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:
Last Name:TUCKER-STICKELS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 MURLEY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-3308
Mailing Address - Country:US
Mailing Address - Phone:608-242-4605
Mailing Address - Fax:
Practice Address - Street 1:230 MURLEY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-3308
Practice Address - Country:US
Practice Address - Phone:608-242-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38352300Medicaid