=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083361992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAKEMA TUCKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2022
-----------------------------------------------------
Last Update Date | 03/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10543 S CRATER RD
-----------------------------------------------------
City | SOUTH PRINCE GEORGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23805-7333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-805-6989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9183 COUNTY DR
-----------------------------------------------------
City | DISPUTANTA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23842-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-704-3432
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 0002080829
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------