Provider Demographics
NPI:1710104716
Name:TACKETT, ROBERTA (APRN, RN)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:APRN, RN
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 568
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-0568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1203 AMERICAN GREETING RD
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-4811
Practice Address - Country:US
Practice Address - Phone:606-528-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002865363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0354908Medicare UPIN
KY0295609Medicare UPIN
KY0753803Medicare UPIN
KY0354317Medicare UPIN
KY0354506Medicare UPIN
KY0355709Medicare UPIN
KY0001375Medicare UPIN
KY0354807Medicare UPIN
KY0354112Medicare UPIN