Provider Demographics
NPI:1881035962
Name:TACKITT, AMANDA JO (LPN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:TACKITT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 HUDSON SPRING RD
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-1717
Mailing Address - Country:US
Mailing Address - Phone:731-364-5616
Mailing Address - Fax:
Practice Address - Street 1:920 UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-1605
Practice Address - Country:US
Practice Address - Phone:931-588-5829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57926164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN57925OtherLPN