Provider Demographics
NPI:1326638040
Name:OTTESEN, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:OTTESEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 S BOWERY WAY
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:724 S 1600 W
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:UT
Practice Address - Zip Code:84664-4347
Practice Address - Country:US
Practice Address - Phone:801-515-6048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9550493-17021835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist