Provider Demographics
NPI:1588134324
Name:SHEPHERD-TACKETT, VIRGINIA A (NP-C)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:A
Last Name:SHEPHERD-TACKETT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 PICKETT LN
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-8569
Mailing Address - Country:US
Mailing Address - Phone:606-874-0112
Mailing Address - Fax:606-874-0115
Practice Address - Street 1:92 PICKETT LN
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-8569
Practice Address - Country:US
Practice Address - Phone:606-874-0112
Practice Address - Fax:606-874-0115
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012790363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily