Healthcare Provider Details

I. General information

NPI: 1043561855
Provider Name (Legal Business Name): JULIE TUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SOUTHPARK SHOPPING CTR
NASHVILLE AR
71852-3307
US

IV. Provider business mailing address

24 SOUTHPARK SHOPPING CTR
NASHVILLE AR
71852-3307
US

V. Phone/Fax

Practice location:
  • Phone: 870-845-3813
  • Fax: 870-845-3808
Mailing address:
  • Phone: 870-845-3813
  • Fax: 870-845-3808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License NumberCPED3851
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: