Healthcare Provider Details

I. General information

NPI: 1265196869
Provider Name (Legal Business Name): REBEKAH MARIE TUCKER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2021
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 LOVE AVE
TIFTON GA
31794-4406
US

IV. Provider business mailing address

612 LOVE AVE
TIFTON GA
31794-4406
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-3300
  • Fax: 229-388-1948
Mailing address:
  • Phone: 229-391-3300
  • Fax: 229-388-1948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN219762
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: