Provider Demographics
NPI:1689136632
Name:TUCKER, NICHOLE
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:
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 1:1276 SAINT CYR RD STE 114
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63137-1224
Mailing Address - Country:US
Mailing Address - Phone:314-738-9941
Mailing Address - Fax:314-738-9961
Practice Address - Street 1:1276 SAINT CYR RD STE 114
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63137-1224
Practice Address - Country:US
Practice Address - Phone:314-738-9941
Practice Address - Fax:314-738-9961
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide