Healthcare Provider Details

I. General information

NPI: 1962020180
Provider Name (Legal Business Name): BEATRICE TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E NIZHONI BLVD APT 10
GALLUP NM
87301-7111
US

IV. Provider business mailing address

220 E NIZHONI BLVD APT 10
GALLUP NM
87301-7111
US

V. Phone/Fax

Practice location:
  • Phone: 903-930-7454
  • Fax:
Mailing address:
  • Phone: 903-930-7454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberA4912
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: