Provider Demographics
NPI:1295060499
Name:TUCKER, KELLY ANN (MRC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 PONDEROSA DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-3129
Mailing Address - Country:US
Mailing Address - Phone:303-853-3456
Mailing Address - Fax:303-289-6962
Practice Address - Street 1:4371 E 72ND AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-1471
Practice Address - Country:US
Practice Address - Phone:303-853-3456
Practice Address - Fax:303-289-6962
Is Sole Proprietor?:No
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker