Healthcare Provider Details

I. General information

NPI: 1215916044
Provider Name (Legal Business Name): REVA DUFF TACKETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 NICHOLASVILLE RD STE 702
LEXINGTON KY
40503-1489
US

IV. Provider business mailing address

1720 NICHOLASVILLE RD STE 702
LEXINGTON KY
40503-1489
US

V. Phone/Fax

Practice location:
  • Phone: 859-264-8811
  • Fax: 859-264-8822
Mailing address:
  • Phone: 859-264-8811
  • Fax: 859-264-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number20064
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: