=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366172520
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANZANDRA DESHA TUCKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2022
-----------------------------------------------------
Last Update Date | 06/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 108 RAMONA DR SW
-----------------------------------------------------
City | MILLEDGEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31061-4456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-251-0166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 RAMONA DR SW
-----------------------------------------------------
City | MILLEDGEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31061-4456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-251-0166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246RP1900X
-----------------------------------------------------
Taxonomy Name | Phlebotomy Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------