Healthcare Provider Details

I. General information

NPI: 1700795994
Provider Name (Legal Business Name): SHAMIERA LATREI TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 SKYLINE DR
MELROSE NY
12121-1921
US

IV. Provider business mailing address

93 SKYLINE DR
MELROSE NY
12121-1921
US

V. Phone/Fax

Practice location:
  • Phone: 518-469-7716
  • Fax: 518-274-6511
Mailing address:
  • Phone: 518-469-7716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number332693
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: