Provider Demographics
NPI:1336225309
Name:FLUKER, TAWANDA (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAWANDA
Middle Name:
Last Name:FLUKER
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:TAWANDA
Other - Middle Name:
Other - Last Name:FLUKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:M A CCC-SLP
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-0271
Mailing Address - Country:US
Mailing Address - Phone:678-732-5896
Mailing Address - Fax:
Practice Address - Street 1:148 WINDCROFT CT NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-3783
Practice Address - Country:US
Practice Address - Phone:678-732-5896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA383330152DMedicaid