Healthcare Provider Details

I. General information

NPI: 1457958910
Provider Name (Legal Business Name): COURTNEY TUCKER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 DENNY AVE
PASCAGOULA MS
39581-5301
US

IV. Provider business mailing address

11526 OLD HIGHWAY 43
AXIS AL
36505-4305
US

V. Phone/Fax

Practice location:
  • Phone: 228-809-5000
  • Fax:
Mailing address:
  • Phone: 251-591-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number904215
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: