MEDICARE: MR. TUCKER LEE BRADY FNP

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	363LF0000X	Family Nurse Practitioner	903771	MS

General Provider Information

NPI Number	:	1679107692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TUCKER LEE BRADY FNP

Provider Business Mailing Address
First Line	:	1522 OLD HIGHWAY 51 NE
Second Line	:
City	:	BROOKHAVEN
State	:	MS
Zip	:	39601-9553
Country	:	US
Telephone Number	:	601-754-2690
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 BROOKMAN DR EXT
Second Line	:
City	:	BROOKHAVEN
State	:	MS
Zip	:	39601-2371
Country	:	US
Telephone Number	:	601-823-5275
Fax Number	:

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

Provider Enumeration Date	:	02/28/2020
Last Update Date	:	01/09/2025

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