Provider Demographics
NPI:1881748440
Name:TUCKER, MARY WALL (FNP)
Entity type:Individual
Prefix:
First Name:MARY WALL
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:FNP
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 360
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-0360
Mailing Address - Country:US
Mailing Address - Phone:888-339-6065
Mailing Address - Fax:828-538-4441
Practice Address - Street 1:317 N KING ST STE B
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-4349
Practice Address - Country:US
Practice Address - Phone:828-693-9199
Practice Address - Fax:828-692-2487
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC72955363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC4942COtherMEDICARE PTAN(LFM)
NC154W2OtherBCBS NC(LFM)
NC1881748440Medicaid
NCP02130832OtherRAILROAD MEDICARE PTAN(LFM)