Provider Demographics
NPI:1104521657
Name:TACKETT, KAYLA SHANE (PMHNP-BC, APRN)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:SHANE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:PMHNP-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 TOLLAGE CRK
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3305
Mailing Address - Country:US
Mailing Address - Phone:606-230-2255
Mailing Address - Fax:606-437-3001
Practice Address - Street 1:484 TOLLAGE CRK
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3305
Practice Address - Country:US
Practice Address - Phone:606-230-2255
Practice Address - Fax:606-437-3001
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4000516363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1104521657Medicaid
KY7100894480Medicaid
VA1104521657Medicaid