Healthcare Provider Details

I. General information

NPI: 1891614053
Provider Name (Legal Business Name): RICKEA CHANTE TARVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 N MAIN ST
WADLEY GA
30477-4903
US

IV. Provider business mailing address

6949 CLARKS MILL RD
LOUISVILLE GA
30434-4123
US

V. Phone/Fax

Practice location:
  • Phone: 478-494-3502
  • Fax:
Mailing address:
  • Phone: 478-494-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN278529
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: