Provider Demographics
NPI:1942534532
Name:TUCKER, MARY SUE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SUE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1186 TRUXELL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906
Mailing Address - Country:US
Mailing Address - Phone:419-747-6283
Mailing Address - Fax:
Practice Address - Street 1:1186 TRUXELL DRIVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906
Practice Address - Country:US
Practice Address - Phone:419-747-6283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 089629164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse