Healthcare Provider Details

I. General information

NPI: 1174828180
Provider Name (Legal Business Name): DEADRA RENEA TUCKER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2011
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

491 MAJORS BLVD
LYNCHBURG TN
37352-8344
US

IV. Provider business mailing address

5135 WINCHESTER HWY
LYNCHBURG TN
37352-8458
US

V. Phone/Fax

Practice location:
  • Phone: 931-759-4727
  • Fax: 931-759-4729
Mailing address:
  • Phone: 931-759-4949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15536
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: