Healthcare Provider Details

I. General information

NPI: 1114280997
Provider Name (Legal Business Name): KENNETH WAYNE TUCKER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E GEORGIA AVE
RUSTON LA
71270-3926
US

IV. Provider business mailing address

802 MARION HWY
FARMERVILLE LA
71241-9215
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-4120
  • Fax: 318-251-4181
Mailing address:
  • Phone: 318-368-7283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN106423
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: