Provider Demographics
NPI:1134458243
Name:TACKETT, TONI T (APRN)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:T
Last Name:TACKETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W LOCKE ST STE C
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-3326
Mailing Address - Country:US
Mailing Address - Phone:870-898-4100
Mailing Address - Fax:870-898-4136
Practice Address - Street 1:450 W LOCKE ST
Practice Address - Street 2:
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822-3326
Practice Address - Country:US
Practice Address - Phone:870-898-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR196496758Medicaid
AR196496758Medicaid