Provider Demographics
NPI:1689439192
Name:TUCKER, CIARA SHONTELL
Entity Type:Individual
Prefix:MS
First Name:CIARA
Middle Name:SHONTELL
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 1:4053 SAINT FERDINAND AVE APT D
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-3214
Mailing Address - Country:US
Mailing Address - Phone:314-372-1149
Mailing Address - Fax:
Practice Address - Street 1:4053 SAINT FERDINAND AVE APT D
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-3214
Practice Address - Country:US
Practice Address - Phone:314-372-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014161376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty