Provider Demographics
NPI:1831777630
Name:TACKETT, KELLY JO (MD MPH)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JO
Last Name:TACKETT
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 DELANEY AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6003
Mailing Address - Country:US
Mailing Address - Phone:910-667-9222
Mailing Address - Fax:
Practice Address - Street 1:2511 DELANEY AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6003
Practice Address - Country:US
Practice Address - Phone:910-667-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCTACK-I2KC0C390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program