Provider Demographics
NPI:1609361807
Name:TUCK, ELIZABETH DAWN (FNP-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:DAWN
Last Name:TUCK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1866 S MOREY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651-9190
Mailing Address - Country:US
Mailing Address - Phone:231-908-8888
Mailing Address - Fax:833-989-2153
Practice Address - Street 1:1866 S MOREY RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-9190
Practice Address - Country:US
Practice Address - Phone:231-908-8888
Practice Address - Fax:833-989-2153
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704272712363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704272712OtherLICENSE