Provider Demographics
NPI:1831707488
Name:TUCKER, KHUDSIATU
Entity type:Individual
Prefix:
First Name:KHUDSIATU
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 1:5632 ANNAPOLIS RD STE 11
Mailing Address - Street 2:
Mailing Address - City:BLADENSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20710-2213
Mailing Address - Country:US
Mailing Address - Phone:240-486-7097
Mailing Address - Fax:
Practice Address - Street 1:5632 ANNAPOLIS RD STE 11
Practice Address - Street 2:
Practice Address - City:BLADENSBURG
Practice Address - State:MD
Practice Address - Zip Code:20710-2213
Practice Address - Country:US
Practice Address - Phone:240-486-7097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR166523363LF0000X, 363LP0808X
VA0024179570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily