Healthcare Provider Details

I. General information

NPI: 1942609003
Provider Name (Legal Business Name): NATALIE DANIELLE TACKE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NATALIE DANIELLE CUTCHIN

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 GODWIN BLVD FL 1
SUFFOLK VA
23434-8038
US

IV. Provider business mailing address

2800 GODWIN BLVD FL 1
SUFFOLK VA
23434-8038
US

V. Phone/Fax

Practice location:
  • Phone: 757-934-4821
  • Fax: 757-934-4276
Mailing address:
  • Phone: 757-934-4821
  • Fax: 757-934-4276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024171821
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: