Provider Demographics
NPI:1750023164
Name:TACKETT, AMBER (NP-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 KEYSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4054
Mailing Address - Country:US
Mailing Address - Phone:951-990-9415
Mailing Address - Fax:
Practice Address - Street 1:6333 KEYSTONE WAY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4054
Practice Address - Country:US
Practice Address - Phone:951-990-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020645363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner