Provider Demographics
NPI:1962741165
Name:TACKIE, MICHELLE ANN (RN)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:ANN
Last Name:TACKIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 COMO RD
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-1904
Mailing Address - Country:US
Mailing Address - Phone:617-953-5058
Mailing Address - Fax:617-364-7198
Practice Address - Street 1:75 COMO RD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-1904
Practice Address - Country:US
Practice Address - Phone:617-953-5058
Practice Address - Fax:617-364-7198
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS34977173163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse