MEDICARE: ELIZABETH DAWN TUCK FNP-C

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	4704272712	MI
2	363LP2300X	Primary Care Nurse Practitioner	4704272712	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4704272712	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1609361807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH DAWN TUCK FNP-C

Provider Business Mailing Address
First Line	:	1866 S MOREY RD
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-9190
Country	:	US
Telephone Number	:	231-908-8888
Fax Number	:	833-989-2153

Provider Business Practice Location Address
First Line	:	1866 S MOREY RD
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-9190
Country	:	US
Telephone Number	:	231-908-8888
Fax Number	:	833-989-2153

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

Provider Enumeration Date	:	06/29/2018
Last Update Date	:	09/28/2022

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