Provider Demographics
NPI:1518495522
Name:TUCK, SHELLI (AGPCNP-C, MS, BSN)
Entity Type:Individual
Prefix:
First Name:SHELLI
Middle Name:
Last Name:TUCK
Suffix:
Gender:F
Credentials:AGPCNP-C, MS, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34279 ASPEN PARK DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-6105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34279 ASPEN PARK DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-6105
Practice Address - Country:US
Practice Address - Phone:586-243-9120
Practice Address - Fax:586-610-2722
Is Sole Proprietor?:No
Enumeration Date:2017-06-03
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG05170100363LA2200X, 363LG0600X, 363LP2300X
MIAG07220208363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care