Provider Demographics
NPI:1770092827
Name:TUCKER, TATASHA (ST)
Entity type:Individual
Prefix:
First Name:TATASHA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 NORTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-1597
Mailing Address - Country:US
Mailing Address - Phone:229-888-5485
Mailing Address - Fax:
Practice Address - Street 1:2614 NORTHGATE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-1597
Practice Address - Country:US
Practice Address - Phone:229-888-5485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor