Provider Demographics
NPI:1649862004
Name:TUCKER, AMANDA KAYLEIGH
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAYLEIGH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3400
Mailing Address - Country:US
Mailing Address - Phone:318-429-6938
Mailing Address - Fax:
Practice Address - Street 1:856 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3400
Practice Address - Country:US
Practice Address - Phone:318-429-6938
Practice Address - Fax:318-629-2870
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator