Healthcare Provider Details

I. General information

NPI: 1154697829
Provider Name (Legal Business Name): JOAN LAVONNE TACKETT APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 SUMMIT AVE
GREENSBORO NC
27405-7007
US

IV. Provider business mailing address

PO BOX 746724
ATLANTA GA
30374-6724
US

V. Phone/Fax

Practice location:
  • Phone: 336-200-7010
  • Fax:
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA03553ANP
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5016176
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: