Healthcare Provider Details

I. General information

NPI: 1275409211
Provider Name (Legal Business Name): TERESA MARIE TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2025
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 BLUFF VIEW CT APT 202
WOODBRIDGE VA
22192-1763
US

IV. Provider business mailing address

3221 BLUFF VIEW CT APT 202
WOODBRIDGE VA
22192-1763
US

V. Phone/Fax

Practice location:
  • Phone: 703-504-7867
  • Fax:
Mailing address:
  • Phone: 703-504-7867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-109391
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: