Provider Demographics
NPI:1336860667
Name:TACKETT, DEBRA (MSN, RN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:TACKETT
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 MARGARET ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2968
Mailing Address - Country:US
Mailing Address - Phone:518-565-4067
Mailing Address - Fax:518-565-4509
Practice Address - Street 1:133 MARGARET ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2926
Practice Address - Country:US
Practice Address - Phone:518-565-4067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY690862163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse