Provider Demographics
NPI:1063871994
Name:TACKETT, EMILY JANE (CPNP)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:JANE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:JANE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3950 AUSTELL RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1121
Mailing Address - Country:US
Mailing Address - Phone:470-732-5201
Mailing Address - Fax:470-792-5209
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:470-732-5201
Practice Address - Fax:470-792-5209
Is Sole Proprietor?:No
Enumeration Date:2016-02-20
Last Update Date:2016-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN204462363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics