Provider Demographics
NPI:1407008014
Name:TACKIE, ESTHER (LPN)
Entity Type:Individual
Prefix:
First Name:ESTHER
Middle Name:
Last Name:TACKIE
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 1:3012 BAINBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1707
Mailing Address - Country:US
Mailing Address - Phone:718-933-9034
Mailing Address - Fax:718-933-9034
Practice Address - Street 1:3012 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1707
Practice Address - Country:US
Practice Address - Phone:718-933-9034
Practice Address - Fax:718-933-9034
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY240897164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02127466Medicaid