Provider Demographics
NPI:1881341253
Name:TACKETT, DOUGLAS (AGNP-C)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:TACKETT
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8853 E HENDERSON TRL
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34450-8879
Mailing Address - Country:US
Mailing Address - Phone:330-322-6856
Mailing Address - Fax:
Practice Address - Street 1:801 MEDICAL CT E
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4623
Practice Address - Country:US
Practice Address - Phone:352-765-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11018465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine