Provider Demographics
NPI:1194260828
Name:TACKEL, AMY CHRISTINE (NP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:CHRISTINE
Last Name:TACKEL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MR
Other - First Name:AMY
Other - Middle Name:ARNOLD
Other - Last Name:ALLEMAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-377-6570
Practice Address - Street 1:1011 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3443
Practice Address - Country:US
Practice Address - Phone:817-225-6888
Practice Address - Fax:817-377-6570
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily