Healthcare Provider Details

I. General information

NPI: 1740191808
Provider Name (Legal Business Name): SHANIQUA TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CUDDY AVE
YOUNGSTOWN OH
44505-3303
US

IV. Provider business mailing address

920 CUDDY AVE
YOUNGSTOWN OH
44505-3303
US

V. Phone/Fax

Practice location:
  • Phone: 330-999-1790
  • Fax:
Mailing address:
  • Phone: 330-999-1790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN.460928
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: