Healthcare Provider Details

I. General information

NPI: 1104706365
Provider Name (Legal Business Name): KYLE DAVID TUCKER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2025
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W JANSS RD
THOUSAND OAKS CA
91360-1847
US

IV. Provider business mailing address

840 MOFFATT CIR
SIMI VALLEY CA
93065-5633
US

V. Phone/Fax

Practice location:
  • Phone: 805-370-4436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number95255871
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039691
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95039691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: