Basic Information
| Provider Information | |||||||||
| NPI: | 1881047447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACKETT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TACKETT | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1791 ALUM CREEK DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432071708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144458131 | ||||||||
| FaxNumber: | 6148278380 | ||||||||
| Practice Location | |||||||||
| Address1: | 88 N. SANDUSKY ST | ||||||||
| Address2: | |||||||||
| City: | DELAWARE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402033800 | ||||||||
| FaxNumber: | 7402033799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2016 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | PN127169-MEDS | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.