Provider Demographics
NPI:1942299789
Name:TUCKER, MARY KNUTH (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KNUTH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 WILLOW LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3551
Mailing Address - Country:US
Mailing Address - Phone:336-667-0335
Mailing Address - Fax:336-667-4434
Practice Address - Street 1:1405 WILLOW LN
Practice Address - Street 2:SUITE A
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3551
Practice Address - Country:US
Practice Address - Phone:336-667-0335
Practice Address - Fax:336-667-4434
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200814363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0481610001OtherDMERC/PGBA
NC0575OtherMEDICARE GROUP
NC8902938Medicaid
NC0575Medicare PIN
NC0575OtherMEDICARE GROUP
S70584Medicare UPIN