Provider Demographics
NPI:1720610587
Name:TACKETT, CARLYN E (APRN)
Entity Type:Individual
Prefix:
First Name:CARLYN
Middle Name:E
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 1:16 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4232
Mailing Address - Country:US
Mailing Address - Phone:918-947-9117
Mailing Address - Fax:
Practice Address - Street 1:16 S WATER ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4232
Practice Address - Country:US
Practice Address - Phone:918-347-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0113970163W00000X
OK113970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse