Provider Demographics
NPI:1891382750
Name:TACKETT, LORRIE LEE
Entity Type:Individual
Prefix:
First Name:LORRIE
Middle Name:LEE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44905-2015
Mailing Address - Country:US
Mailing Address - Phone:419-565-6075
Mailing Address - Fax:
Practice Address - Street 1:1482 MAXWELL DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2376
Practice Address - Country:US
Practice Address - Phone:419-565-6075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0251257Medicaid