Provider Demographics
NPI:1629294194
Name:TUCKER, KERRI L (NP)
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-345-5250
Mailing Address - Fax:208-345-2364
Practice Address - Street 1:100 E IDAHO ST
Practice Address - Street 2:STE 400
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6267
Practice Address - Country:US
Practice Address - Phone:208-345-5250
Practice Address - Fax:208-345-2364
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP 807A363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology