Healthcare Provider Details

I. General information

NPI: 1780445296
Provider Name (Legal Business Name): HALEY AMANDA TUCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 COOMBS FARM RD STE 106
MORGANTOWN WV
26508-1157
US

IV. Provider business mailing address

453 VAN VOORHIS RD
MORGANTOWN WV
26505-3408
US

V. Phone/Fax

Practice location:
  • Phone: 304-212-5663
  • Fax: 304-936-0101
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number117880
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: