Healthcare Provider Details

I. General information

NPI: 1629161666
Provider Name (Legal Business Name): ANNA MARZELLA TUCKER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 10TH ST RHC 4TH FLOOR
INDIANAPOLIS IN
46202-2859
US

IV. Provider business mailing address

8910 PURDUE RD STE 500
INDIANAPOLIS IN
46268-3161
US

V. Phone/Fax

Practice location:
  • Phone: 317-630-7979
  • Fax: 317-630-2668
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number71000988A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: