Provider Demographics
NPI:1942785449
Name:TUCKER, MIEKA LYNNE (BS)
Entity Type:Individual
Prefix:
First Name:MIEKA
Middle Name:LYNNE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17117 GULF BLVD APT 248
Mailing Address - Street 2:
Mailing Address - City:NORTH REDINGTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33708-1412
Mailing Address - Country:US
Mailing Address - Phone:417-848-1677
Mailing Address - Fax:
Practice Address - Street 1:17117 GULF BLVD APT 248
Practice Address - Street 2:
Practice Address - City:NORTH REDINGTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33708-1412
Practice Address - Country:US
Practice Address - Phone:417-848-1677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid