Basic Information
| Provider Information | |||||||||
| NPI: | 1972805281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACKETT | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, ANP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | BARNETT TOWER, STE 605 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148209248 | ||||||||
| FaxNumber: | 2148209258 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 GASTON AVE | ||||||||
| Address2: | BARNETT TOWER, STE 605 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752461800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148209248 | ||||||||
| FaxNumber: | 2148209258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2010 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 595007 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 3126120-01 | 05 | TX | MEDICAID |