Provider Demographics
NPI:1356167316
Name:TUCKER, SHAVON
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 W KILEY AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2238
Mailing Address - Country:US
Mailing Address - Phone:414-322-4595
Mailing Address - Fax:414-446-5836
Practice Address - Street 1:3314 W ORIOLE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4101
Practice Address - Country:US
Practice Address - Phone:414-210-4110
Practice Address - Fax:414-446-5836
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI515877376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty