Healthcare Provider Details

I. General information

NPI: 1891684957
Provider Name (Legal Business Name): EMILY KALYN GRACE TACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 BYPASS RD BLDG A
PIKEVILLE KY
41501-1602
US

IV. Provider business mailing address

PO BOX 432
PIKEVILLE KY
41502-0432
US

V. Phone/Fax

Practice location:
  • Phone: 606-430-2208
  • Fax: 606-218-7508
Mailing address:
  • Phone: 606-430-2208
  • Fax: 606-218-7508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC906
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: