Provider Demographics
NPI:1912130048
Name:TACKETT, CATHY SUE (APRN)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:SUE
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:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-0550
Mailing Address - Country:US
Mailing Address - Phone:606-796-3029
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:142 DEPOT DR
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175
Practice Address - Country:US
Practice Address - Phone:606-932-2271
Practice Address - Fax:606-932-2273
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007355363LF0000X
OH1083-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3014811Medicaid
KY7100086830Medicaid
WV3810021969Medicaid
OHH049920Medicare PIN
KYK023400Medicare PIN