Provider Demographics
NPI:1730951443
Name:TUCKER, PAYTON BRIANNE
Entity type:Individual
Prefix:
First Name:PAYTON
Middle Name:BRIANNE
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 1:123 COUNTY ROAD 2309
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-8110
Mailing Address - Country:US
Mailing Address - Phone:419-690-9636
Mailing Address - Fax:
Practice Address - Street 1:123 COUNTY ROAD 2309
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-8110
Practice Address - Country:US
Practice Address - Phone:419-690-9636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1011914163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse