Provider Demographics
NPI:1134823784
Name:TACKETT, HOLLY NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:NICOLE
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 1:4439 STATE ROUTE 159
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-8207
Mailing Address - Country:US
Mailing Address - Phone:740-779-4393
Mailing Address - Fax:
Practice Address - Street 1:4439 STATE ROUTE 159 STE G70
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-7203
Practice Address - Country:US
Practice Address - Phone:740-779-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0032936363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily