Healthcare Provider Details

I. General information

NPI: 1265959704
Provider Name (Legal Business Name): BENJAMIN TACKETT FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 08/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 STOLLINGS AVE STE 1
LOGAN WV
25601-4035
US

IV. Provider business mailing address

140 STOLLINGS AVE STE 1
LOGAN WV
25601-4035
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-2555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number66717
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: