Provider Demographics
NPI:1063099554
Name:TACKETT, KENNETH LEE (RN, CNP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:TACKETT
Suffix:
Gender:M
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 DUNLAVY ST APT 5118
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-5441
Mailing Address - Country:US
Mailing Address - Phone:601-927-7224
Mailing Address - Fax:
Practice Address - Street 1:4300 DUNLAVY ST APT 5118
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-5441
Practice Address - Country:US
Practice Address - Phone:601-927-7224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032032363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health