Provider Demographics
NPI:1295388486
Name:TACKETT, TIFFANY ANN (FNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:TACKETT
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 1:6701 HERITAGE PKWY STE 165
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-8700
Mailing Address - Country:US
Mailing Address - Phone:469-786-5890
Mailing Address - Fax:
Practice Address - Street 1:6701 HERITAGE PKWY STE 165
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-8700
Practice Address - Country:US
Practice Address - Phone:469-786-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX957191363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner