Provider Demographics
NPI:1861797151
Name:TACKETT, TAMARA L (NP)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:L
Last Name:TACKETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:SUITE 401
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC4459363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1776Medicaid
SCAA65259068Medicare PIN
SCNP1776Medicaid
SCAA6525Medicare PIN
SCAA65253365Medicare PIN