Provider Demographics
NPI:1972745156
Name:TUCKER, BRONYA KAY (NP-C)
Entity Type:Individual
Prefix:
First Name:BRONYA
Middle Name:KAY
Last Name:TUCKER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1615
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-1615
Mailing Address - Country:US
Mailing Address - Phone:304-285-3679
Mailing Address - Fax:304-285-3694
Practice Address - Street 1:1325 LOCUST AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-1435
Practice Address - Country:US
Practice Address - Phone:304-367-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV50676207QA0401X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV50676OtherLICENSE
NP30391Medicare PIN