Healthcare Provider Details

I. General information

NPI: 1265096127
Provider Name (Legal Business Name): CHARMAINE TUCK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46165 WESTLAKE DR
STERLING VA
20165-5872
US

IV. Provider business mailing address

43172 FLEUR DR
LEESBURG VA
20176-5015
US

V. Phone/Fax

Practice location:
  • Phone: 703-433-1555
  • Fax:
Mailing address:
  • Phone: 334-313-0678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024176765
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024176765
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: