1568500072 NPI number — AMY C COLLINS TUCKER OTRL

Table of content: AMY C COLLINS TUCKER OTRL (NPI 1568500072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568500072 NPI number — AMY C COLLINS TUCKER OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
AMY
Provider Middle Name:
C COLLINS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLLINS
Provider Other First Name:
AMY
Provider Other Middle Name:
CHRISTINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568500072
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11549 SUTHERLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-485-1121
Provider Business Mailing Address Fax Number:
859-485-1121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11549 SUTHERLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41094-7412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-485-1121
Provider Business Practice Location Address Fax Number:
859-485-1121
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  R1561 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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