MEDICARE: KATIE H TUCK CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	1072378	AL
2	363LA2200X	Adult Health Nurse Practitioner	1-072378	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	051542593	OTHER	AL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	Z08424	OTHER	AL	VIVA

General Provider Information

NPI Number	:	1043402555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE H TUCK CRNP

Provider Business Mailing Address
First Line	:	2470 ROCKY RIDGE RD
Second Line	:
City	:	VESTAVIA
State	:	AL
Zip	:	35243-2833
Country	:	US
Telephone Number	:	205-978-3336
Fax Number	:	205-503-4915

Provider Business Practice Location Address
First Line	:	2470 ROCKY RIDGE RD
Second Line	:
City	:	VESTAVIA
State	:	AL
Zip	:	35243-2833
Country	:	US
Telephone Number	:	205-978-3336
Fax Number	:	205-503-4915

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2007
Last Update Date	:	09/08/2014

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