Provider Demographics
NPI:1760945729
Name:TACKETT, CHADWICK TREI (MSN, FNP)
Entity Type:Individual
Prefix:
First Name:CHADWICK
Middle Name:TREI
Last Name:TACKETT
Suffix:
Gender:M
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 FITZROY LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6354
Mailing Address - Country:US
Mailing Address - Phone:606-255-7466
Mailing Address - Fax:
Practice Address - Street 1:230 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40507-1340
Practice Address - Country:US
Practice Address - Phone:859-309-4839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1135877163W00000X
KY3013650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse