Provider Demographics
NPI:1003508797
Name:TACKETT, TAYLOR GRACE (DOCTOR OF OPTOMETRY)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:GRACE
Last Name:TACKETT
Suffix:
Gender:F
Credentials:DOCTOR OF OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:7087 HIGHWAY 524
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-6552
Mailing Address - Country:US
Mailing Address - Phone:256-460-5793
Mailing Address - Fax:
Practice Address - Street 1:14378 HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-2568
Practice Address - Country:US
Practice Address - Phone:256-332-1355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-F21152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist