Provider Demographics
NPI:1548428865
Name:TUCKER, CATHY (LLPN)
Entity Type:Individual
Prefix:MRS
First Name:CATHY
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LLPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-1607
Mailing Address - Country:US
Mailing Address - Phone:609-892-2995
Mailing Address - Fax:
Practice Address - Street 1:1653 BEACH AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-1607
Practice Address - Country:US
Practice Address - Phone:609-892-2995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181145364SM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02759593Medicaid