Healthcare Provider Details

I. General information

NPI: 1053966168
Provider Name (Legal Business Name): KATIE TACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 XENIA AVE
DAYTON OH
45410-1824
US

IV. Provider business mailing address

3400 IDYLWILDE BLVD
DAYTON OH
45414-5514
US

V. Phone/Fax

Practice location:
  • Phone: 937-949-1524
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberFPS.00417
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: