Provider Demographics
NPI:1356992804
Name:TUCKER, THERESA ANN
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
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:PO BOX 33313
Mailing Address - Street 2:
Mailing Address - City:FORT LEWIS
Mailing Address - State:WA
Mailing Address - Zip Code:98433-0313
Mailing Address - Country:US
Mailing Address - Phone:360-832-3067
Mailing Address - Fax:
Practice Address - Street 1:9411 395TH ST CT E
Practice Address - Street 2:
Practice Address - City:EATONVILLE
Practice Address - State:WA
Practice Address - Zip Code:98328-9843
Practice Address - Country:US
Practice Address - Phone:360-832-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider