Provider Demographics
NPI:1619313897
Name:TUCKER, MORIAH DIANE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MORIAH
Middle Name:DIANE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 HEATHER DR
Mailing Address - Street 2:APT. 3D
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45405-1739
Mailing Address - Country:US
Mailing Address - Phone:937-903-0399
Mailing Address - Fax:
Practice Address - Street 1:563 HEATHER DR
Practice Address - Street 2:APT. 3D
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-1739
Practice Address - Country:US
Practice Address - Phone:937-903-0399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-15
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH191305163W00000X
OH026583363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse