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General NPI Number Information
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NPI Number | 1104521657
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Entity Type | Individual
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Provider Name | KAYLA SHANE TACKETT PMHNP-BC, APRN
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Gender | Female
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Dates
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Enumeration Date | 04/04/2023
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Last Update Date | 08/03/2023
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Provider Practice Location Address
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Address Line | 484 TOLLAGE CRK
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City | PIKEVILLE
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State | KY
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Zip | 41501-3305
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Country | US
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Telephone | 606-230-2255
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Fax | 606-437-3001
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Provider Business Mailing Address
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Address Line | 484 TOLLAGE CRK
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City | PIKEVILLE
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State | KY
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Zip | 41501-3305
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Country | US
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Telephone | 606-230-2255
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Fax | 606-437-3001
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 4000516
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License Number State | KY
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