Provider Demographics
NPI:1477855468
Name:TACKETT, SHERI LYNNE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:SHERI
Middle Name:LYNNE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-6911
Mailing Address - Country:US
Mailing Address - Phone:671-645-5500
Mailing Address - Fax:
Practice Address - Street 1:133 ROUTE 3
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929
Practice Address - Country:US
Practice Address - Phone:671-645-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GURE1896163W00000X
AK1177176B00000X, 363LF0000X
GUNP0130176B00000X, 363LF0000X
GURE1896 / NP0130363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No176B00000XOther Service ProvidersMidwife
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUH107377Medicare Oscar/Certification