Healthcare Provider Details

I. General information

NPI: 1285607648
Provider Name (Legal Business Name): SHARON TUCKETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 QUARTZ DR STE 201
VILLA RICA GA
30180
US

IV. Provider business mailing address

119 AMBULANCE DR STE 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-3839
  • Fax: 770-456-3846
Mailing address:
  • Phone: 770-838-8710
  • Fax: 770-838-8563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number03609
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number03609
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: