Provider Demographics
NPI:1447277934
Name:TACKETT, REBECCA L (ARNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:L
Last Name:TACKETT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 DIXIE HWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:FT WRIGHT
Mailing Address - State:KY
Mailing Address - Zip Code:41011-2792
Mailing Address - Country:US
Mailing Address - Phone:859-341-5757
Mailing Address - Fax:859-426-7134
Practice Address - Street 1:1955 DIXIE HWY
Practice Address - Street 2:SUITE D
Practice Address - City:FT WRIGHT
Practice Address - State:KY
Practice Address - Zip Code:41011-2792
Practice Address - Country:US
Practice Address - Phone:859-341-5757
Practice Address - Fax:859-426-7134
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003239363LF0000X
KY3239P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78005840Medicaid
KYP400039070Medicare PIN
OH0970105Medicare PIN
KY78005840Medicaid
KYP34024Medicare UPIN