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General NPI Number Information
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NPI Number | 1497752968
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Entity Type | Individual
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Provider Name | LORI ANNE TACKMAN MD
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Gender | Female
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 10/26/2020
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Provider Practice Location Address
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Address Line | 20 MEDICAL CAMPUS DR NW STE 205
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City | SUPPLY
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State | NC
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Zip | 28462
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Country | US
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Telephone | 910-721-4400
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Fax | 910-721-4409
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Provider Business Mailing Address
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Address Line | PO BOX 60447
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City | CHARLOTTE
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State | NC
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Zip | 28260-0447
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Country | US
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Telephone |
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Fax |
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2000-00146
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License Number State | NC
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