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General NPI Number Information
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NPI Number | 1528193588
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Entity Type | Individual
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Provider Name | KENYA TUCKER PA
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Gender | Female
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 07/13/2023
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Provider Practice Location Address
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Address Line | 6524 OLD NATIONAL HWY STE 203
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City | ATLANTA
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State | GA
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Zip | 30349-4853
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Country | US
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Telephone | 770-731-1098
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Fax | 404-296-1850
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Provider Business Mailing Address
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Address Line | 42 CARRIAGE OAKS DR # 111
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City | TYRONE
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State | GA
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Zip | 30290-1684
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Country | US
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Telephone | 404-314-5248
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Fax | 770-731-1098
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 004484
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License Number State | GA
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