Provider Demographics
NPI:1497197636
Name:TUCKER, NICOLE A
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
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 1:719 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3501
Mailing Address - Country:US
Mailing Address - Phone:201-926-9757
Mailing Address - Fax:
Practice Address - Street 1:719 E 84TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3501
Practice Address - Country:US
Practice Address - Phone:201-926-9757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 174H00000X
NJ173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No173C00000XOther Service ProvidersReflexologist