Provider Demographics
NPI:1902137516
Name:TACKETT, SHANA LEE
Entity Type:Individual
Prefix:MS
First Name:SHANA
Middle Name:LEE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12330 AGENCY RD
Mailing Address - Street 2:PARKER INDIAN HEALTH SERVICES
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344
Mailing Address - Country:US
Mailing Address - Phone:928-669-3130
Mailing Address - Fax:928-669-3131
Practice Address - Street 1:12330 AGENCY RD
Practice Address - Street 2:PARKER INDIAN HEALTH CENTER
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344
Practice Address - Country:US
Practice Address - Phone:928-669-3130
Practice Address - Fax:928-669-3131
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program