Provider Demographics
NPI:1013030287
Name:TACKETT, JONI RENAE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JONI
Middle Name:RENAE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2042 SEXTON RD
Mailing Address - Street 2:
Mailing Address - City:AUSTINBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44010-9706
Mailing Address - Country:US
Mailing Address - Phone:440-969-3052
Mailing Address - Fax:
Practice Address - Street 1:2042 SEXTON RD
Practice Address - Street 2:
Practice Address - City:AUSTINBURG
Practice Address - State:OH
Practice Address - Zip Code:44010-9706
Practice Address - Country:US
Practice Address - Phone:440-969-3052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 080897164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2174016OtherINDEPENDENT PROVIDER #