Provider Demographics
NPI:1659942175
Name:TUCK, STASHAUN L
Entity Type:Individual
Prefix:
First Name:STASHAUN
Middle Name:L
Last Name:TUCK
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 1:817 BARKINS AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1726
Mailing Address - Country:US
Mailing Address - Phone:937-242-3510
Mailing Address - Fax:
Practice Address - Street 1:817 BARKINS AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1726
Practice Address - Country:US
Practice Address - Phone:937-242-3510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401529920613374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty