Provider Demographics
NPI:1790317774
Name:TUCKER, CASSANDRA KATHLENA B
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:KATHLENA B
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 1:9352 PARK WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4325
Mailing Address - Country:US
Mailing Address - Phone:865-373-1130
Mailing Address - Fax:865-373-1155
Practice Address - Street 1:7565 DANNAHER DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-4029
Practice Address - Country:US
Practice Address - Phone:865-859-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN200449163WE0003X
TN27101363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner