Basic Information
| Provider Information | |||||||||
| NPI: | 1881748440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | MARY WALL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 360 | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287790360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883396065 | ||||||||
| FaxNumber: | 8285384441 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 N KING ST STE B | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287924349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286939199 | ||||||||
| FaxNumber: | 8286922487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 11/12/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 72955 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NC4942C | 01 | NC | MEDICARE PTAN(LFM) | OTHER | 154W2 | 01 | NC | BCBS NC(LFM) | OTHER | 1881748440 | 05 | NC | MEDICAID | P02130832 | 01 | NC | RAILROAD MEDICARE PTAN(LFM) | OTHER |