Healthcare Provider Details

I. General information

NPI: 1275443095
Provider Name (Legal Business Name): DESIREE IDOLLY TUCKER NP BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MACARTHUR BLVD STE 600
NEWPORT BEACH CA
92660-2517
US

IV. Provider business mailing address

504 SONIA
IRVINE CA
92618-5913
US

V. Phone/Fax

Practice location:
  • Phone: 310-696-8169
  • Fax:
Mailing address:
  • Phone: 310-696-8169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: