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General NPI Number Information
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NPI Number | 1679107692
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Entity Type | Individual
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Provider Name | TUCKER LEE BRADY FNP
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Gender | Male
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Dates
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Enumeration Date | 02/28/2020
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Last Update Date | 01/09/2025
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Provider Practice Location Address
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Address Line | 601 BROOKMAN DR EXT
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City | BROOKHAVEN
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State | MS
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Zip | 39601-2371
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Country | US
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Telephone | 601-823-5275
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Fax |
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Provider Business Mailing Address
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Address Line | 1522 OLD HIGHWAY 51 NE
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City | BROOKHAVEN
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State | MS
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Zip | 39601-9553
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Country | US
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Telephone | 601-754-2690
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 903771
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License Number State | MS
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