Provider Demographics
NPI:1952806291
Name:TUCKER, NICOLE ELIZABETH (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DO
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 2792
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2792
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:631 ELM ST SW STE 205
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1952
Practice Address - Country:US
Practice Address - Phone:541-812-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORDO211584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program