Provider Demographics
NPI:1770021123
Name:NACKOS, TINA (CNM)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:NACKOS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1548
Mailing Address - Country:US
Mailing Address - Phone:801-404-5588
Mailing Address - Fax:
Practice Address - Street 1:585 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1548
Practice Address - Country:US
Practice Address - Phone:801-404-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife