Provider Demographics
NPI:1659875292
Name:BLAIR-TUCKER, ALISA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:
Last Name:BLAIR-TUCKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 ANSEL RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-4006
Mailing Address - Country:US
Mailing Address - Phone:216-235-3613
Mailing Address - Fax:
Practice Address - Street 1:1428 ANSEL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-4006
Practice Address - Country:US
Practice Address - Phone:216-235-3613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH126602164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty