Provider Demographics
NPI:1720672751
Name:TACCETTA, CAROL
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:TACCETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1277 W 1650 S
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-8571
Mailing Address - Country:US
Mailing Address - Phone:435-572-0107
Mailing Address - Fax:
Practice Address - Street 1:1277 W 1650 S
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-8571
Practice Address - Country:US
Practice Address - Phone:435-572-0107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-20
Last Update Date:2023-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.082011207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology