Provider Demographics
NPI:1740496579
Name:TACTAC, DONNA (RN)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:TACTAC
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14570 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-2212
Mailing Address - Country:US
Mailing Address - Phone:586-566-6048
Mailing Address - Fax:586-263-8696
Practice Address - Street 1:16200 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1103
Practice Address - Country:US
Practice Address - Phone:586-263-8696
Practice Address - Fax:586-263-8731
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704188742163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health