Provider Demographics
NPI:1457868135
Name:TUCKER, GWENDOLYN RITA (PCA)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:RITA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 WAGGONER
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612
Mailing Address - Country:US
Mailing Address - Phone:419-984-7728
Mailing Address - Fax:
Practice Address - Street 1:206 WAGGONER
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612
Practice Address - Country:US
Practice Address - Phone:419-964-7728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111545Medicaid