Provider Demographics
NPI:1841534328
Name:TUCKER, TANYA NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:NICOLE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 TIMBER CREEK LN APT 15
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1181
Mailing Address - Country:US
Mailing Address - Phone:304-633-9082
Mailing Address - Fax:
Practice Address - Street 1:501 CALDWELL LN
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064-2026
Practice Address - Country:US
Practice Address - Phone:304-744-7064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA001207225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant