Healthcare Provider Details

I. General information

NPI: 1164020467
Provider Name (Legal Business Name): KAYSHA TUCKER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 W MARKET ST
WARREN OH
44485-3069
US

IV. Provider business mailing address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-898-6992
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN175729-MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: