Provider Demographics
NPI:1346688405
Name:TACKETT, BONNIE A (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:A
Last Name:TACKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 RAVEN HILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002
Mailing Address - Country:US
Mailing Address - Phone:913-367-6688
Mailing Address - Fax:913-674-2030
Practice Address - Street 1:810 RAVEN HILL DRIVE
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002
Practice Address - Country:US
Practice Address - Phone:913-367-6688
Practice Address - Fax:913-674-2030
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-37708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine