Provider Demographics
NPI:1689838278
Name:TUCKER, LAURA MICHELLE (LMT, LMP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MICHELLE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 360613
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32936-0613
Mailing Address - Country:US
Mailing Address - Phone:321-720-1088
Mailing Address - Fax:
Practice Address - Street 1:629 LYCHEE PL
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4023
Practice Address - Country:US
Practice Address - Phone:321-720-1088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00022531225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist