Provider Demographics
NPI:1629611751
Name:TACKETT, ANDREA JO (APRN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:JO
Last Name:TACKETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-408-9571
Mailing Address - Fax:606-408-6061
Practice Address - Street 1:2500 STATE ROUTE 5
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-9102
Practice Address - Country:US
Practice Address - Phone:606-408-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-22
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013898363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health