Healthcare Provider Details

I. General information

NPI: 1124322631
Provider Name (Legal Business Name): STEPHANIE TUCKER RCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12011 LEE JACKSON HIGHWAY
FAIRFAX VA
20120
US

IV. Provider business mailing address

14435 SALISBURY PLAIN CT
CENTREVILLE VA
20120-3243
US

V. Phone/Fax

Practice location:
  • Phone: 703-383-5524
  • Fax:
Mailing address:
  • Phone: 703-383-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number0117000749
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: