Provider Demographics
NPI:1851902316
Name:TUCKER, WANDA MICHELLE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:MICHELLE
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 1:2717 NW DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3942
Mailing Address - Country:US
Mailing Address - Phone:580-583-3623
Mailing Address - Fax:
Practice Address - Street 1:2717 NW DENVER AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3942
Practice Address - Country:US
Practice Address - Phone:580-583-3623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor