Healthcare Provider Details

I. General information

NPI: 1235834698
Provider Name (Legal Business Name): DEJANEA TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 HARRY S TRUMAN DR
UPPER MARLBORO MD
20774-2069
US

IV. Provider business mailing address

7751 BELFORT PKWY STE 120
JACKSONVILLE FL
32256-6921
US

V. Phone/Fax

Practice location:
  • Phone: 301-442-6777
  • Fax:
Mailing address:
  • Phone: 904-372-3943
  • Fax: 904-212-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR219532
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1046777
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR219532
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1046777
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR219532
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: