Provider Demographics
NPI:1689924391
Name:TACKETT, JULIE TUTTLE (NP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:TUTTLE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PROVIDER ENROLLMENT
Mailing Address - Street 2:100 KIMEL FOREST DRIVE
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-713-0947
Mailing Address - Fax:
Practice Address - Street 1:1038 BETHANIA RURAL HALL RD
Practice Address - Street 2:
Practice Address - City:RURAL HALL
Practice Address - State:NC
Practice Address - Zip Code:27045-9552
Practice Address - Country:US
Practice Address - Phone:336-716-9270
Practice Address - Fax:336-702-9313
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005790363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006330Medicaid
NC7006330Medicaid