Healthcare Provider Details

I. General information

NPI: 1629520945
Provider Name (Legal Business Name): DIAN TACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIAN KEARNS

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 PEAK ONE DR STE 110
FRISCO CO
80443
US

IV. Provider business mailing address

715 HORIZON DR STE 225
GRAND JUNCTION CO
81506-8743
US

V. Phone/Fax

Practice location:
  • Phone: 970-668-3478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: