Healthcare Provider Details

I. General information

NPI: 1336729243
Provider Name (Legal Business Name): MICHELLE TUCKER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 EMORY AVE
BEAUMONT CA
92223-3117
US

IV. Provider business mailing address

90 EMORY AVE
BEAUMONT CA
92223-3117
US

V. Phone/Fax

Practice location:
  • Phone: 951-442-1807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number95215463
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: