=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073755930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE A. TUCKER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2009
-----------------------------------------------------
Last Update Date | 03/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 WASHINGTON DR
-----------------------------------------------------
City | GALES FERRY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06335-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-941-7689
-----------------------------------------------------
Fax | 860-381-5078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 WASHINGTON DR
-----------------------------------------------------
City | GALES FERRY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06335-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-941-7689
-----------------------------------------------------
Fax | 860-381-5078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHELLE A TUCKER
-----------------------------------------------------
Credential | ND, L.AC.
-----------------------------------------------------
Telephone | 860-941-7689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 000375
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 000358
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------