Provider Demographics
NPI:1902403009
Name:TUCKER, PAMELA D (RN)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:D
Last Name:TUCKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:D
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:355 BLUEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-2883
Mailing Address - Country:US
Mailing Address - Phone:304-425-7111
Mailing Address - Fax:304-425-1138
Practice Address - Street 1:600 TRENT STREET
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740
Practice Address - Country:US
Practice Address - Phone:304-425-7111
Practice Address - Fax:304-425-1138
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1568796027Medicaid
WV55-6025355Medicaid