Healthcare Provider Details

I. General information

NPI: 1033290416
Provider Name (Legal Business Name): MS. WALZETTA L TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 DIXON RD.
ELGIN SC
29045
US

IV. Provider business mailing address

215 N. MAGNOLIA ST.
SUMTER SC
29515-1946
US

V. Phone/Fax

Practice location:
  • Phone: 803-408-1346
  • Fax: 803-408-6961
Mailing address:
  • Phone: 803-775-9364
  • Fax: 803-773-6615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: