Healthcare Provider Details

I. General information

NPI: 1831707488
Provider Name (Legal Business Name): KHUDSIATU TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5632 ANNAPOLIS RD STE 11
BLADENSBURG MD
20710-2213
US

IV. Provider business mailing address

5632 ANNAPOLIS RD STE 11
BLADENSBURG MD
20710-2213
US

V. Phone/Fax

Practice location:
  • Phone: 240-486-7097
  • Fax:
Mailing address:
  • Phone: 240-486-7097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN1023913
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024179570
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR166523
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR166523
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberL8-0011097
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: