Provider Demographics
NPI:1780722975
Name:TACKETT, WANDA F (RN)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:F
Last Name:TACKETT
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:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-0418
Mailing Address - Country:US
Mailing Address - Phone:423-562-8351
Mailing Address - Fax:423-562-1593
Practice Address - Street 1:162 SHARP PERKINS ROAD
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-0418
Practice Address - Country:US
Practice Address - Phone:423-562-8351
Practice Address - Fax:423-562-1593
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000029117163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health