Healthcare Provider Details

I. General information

NPI: 1225537699
Provider Name (Legal Business Name): MS. STEFANIE RENEE TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W DR MLK BLVD
TAMPA FL
33607-6307
US

IV. Provider business mailing address

13551 LUXE AVE APT 108
BRADENTON FL
34211-4507
US

V. Phone/Fax

Practice location:
  • Phone: 813-874-5707
  • Fax:
Mailing address:
  • Phone: 941-914-1077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9230484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: