Provider Demographics
NPI:1679093462
Name:TUCKER, LISA YOLANDA MOORE (FNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:YOLANDA MOORE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 DOCTOR CIR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6502
Mailing Address - Country:US
Mailing Address - Phone:800-491-0909
Mailing Address - Fax:
Practice Address - Street 1:111 DOCTOR CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6502
Practice Address - Country:US
Practice Address - Phone:800-491-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90318163WD0400X
SC24917363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty