Provider Demographics
NPI:1922766583
Name:TACKETT, KATRINA
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:
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 1:637 A MOHAWK DR
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-8985
Mailing Address - Country:US
Mailing Address - Phone:740-250-6699
Mailing Address - Fax:
Practice Address - Street 1:637 A MOHAWK DR
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-8985
Practice Address - Country:US
Practice Address - Phone:740-250-6699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH591052Medicaid