Healthcare Provider Details

I. General information

NPI: 1144405499
Provider Name (Legal Business Name): BETTY JEAN TUCKER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 UTZ ST
FREEPORT NY
11520
US

IV. Provider business mailing address

46 UTZ ST
FREEPORT NY
11520
US

V. Phone/Fax

Practice location:
  • Phone: 516-208-3524
  • Fax: 516-208-3524
Mailing address:
  • Phone: 516-208-3524
  • Fax: 516-208-3524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number290418
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: