Provider Demographics
NPI:1558428284
Name:TUCKER, KATHY RENEE
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:RENEE
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 1:1801 N TRYON ST STE 428
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2843
Mailing Address - Country:US
Mailing Address - Phone:704-347-1500
Mailing Address - Fax:704-331-9041
Practice Address - Street 1:1801 N TRYON ST STE 428
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2843
Practice Address - Country:US
Practice Address - Phone:704-347-1500
Practice Address - Fax:704-331-9041
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC35233747P1801X
NCHC39933747P1801X
NCHC43163747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant