Provider Demographics
NPI:1861430613
Name:TUCKER, SANDRA L (APRN BC)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 TUDOR LN
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-3350
Mailing Address - Country:US
Mailing Address - Phone:803-425-4683
Mailing Address - Fax:
Practice Address - Street 1:2000 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1002
Practice Address - Country:US
Practice Address - Phone:803-576-2784
Practice Address - Fax:803-576-2999
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC282363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics