Provider Demographics
NPI:1962603316
Name:TACCA, BETH L (ANP)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:L
Last Name:TACCA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:L
Other - Last Name:DIVIETRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:22 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-5524
Mailing Address - Country:US
Mailing Address - Phone:716-308-6885
Mailing Address - Fax:
Practice Address - Street 1:760 MILLERSPORT HWY
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-2410
Practice Address - Country:US
Practice Address - Phone:716-446-1435
Practice Address - Fax:716-446-1569
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY543658-1163W00000X
NY304642363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00028045601OtherUNIVERA
NY9514256OtherINDEPENDENT HEALTH
NY000529289001OtherBLUE CROSS
NY02892822Medicaid
NY000529289001OtherBLUE CROSS