MEDICARE: TERRITA I TUCKER LPN

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	164W00000X	Licensed Practical Nurse	145112O	OH

General Provider Information

NPI Number	:	1164703161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRITA I TUCKER LPN

Provider Business Mailing Address
First Line	:	10616 ELMWOOD AVE
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-2621
Country	:	US
Telephone Number	:	216-587-5497
Fax Number	:

Provider Business Practice Location Address
First Line	:	10616 ELMWOOD AVE
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-2621
Country	:	US
Telephone Number	:	216-587-5497
Fax Number	:

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

Provider Enumeration Date	:	09/02/2011
Last Update Date	:	09/02/2011

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