MEDICARE: MRS. MORIAH DIANE TUCKER R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	191305	OH
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	026583	OH

General Provider Information

NPI Number	:	1619313897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MORIAH DIANE TUCKER R.N.

Provider Business Mailing Address
First Line	:	563 HEATHER DR
Second Line	:	APT. 3D
City	:	DAYTON
State	:	OH
Zip	:	45405-1739
Country	:	US
Telephone Number	:	937-903-0399
Fax Number	:

Provider Business Practice Location Address
First Line	:	563 HEATHER DR
Second Line	:	APT. 3D
City	:	DAYTON
State	:	OH
Zip	:	45405-1739
Country	:	US
Telephone Number	:	937-903-0399
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2013
Last Update Date	:	08/13/2020

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