Provider Demographics
NPI:1629401666
Name:TUCKER, STEFANNIE MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:STEFANNIE
Middle Name:MICHELLE
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 1:254 ALLENHURST RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3006
Mailing Address - Country:US
Mailing Address - Phone:716-308-1129
Mailing Address - Fax:
Practice Address - Street 1:254 ALLENHURST RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3006
Practice Address - Country:US
Practice Address - Phone:716-308-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY313497-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse