Healthcare Provider Details

I. General information

NPI: 1235585027
Provider Name (Legal Business Name): TARA L. TACKETT APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA L. CROWDER RN

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 COURT ST STE 100
CHARLESTON WV
25301
US

IV. Provider business mailing address

400 COURT ST STE 100
CHARLESTON WV
25301-1652
US

V. Phone/Fax

Practice location:
  • Phone: 304-347-6120
  • Fax: 304-347-6142
Mailing address:
  • Phone: 304-347-6120
  • Fax: 304-347-6126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN63856-NP-C
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number63856
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN63856-NP-C
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: