1679921134 NPI number — MRS. VIRGINIA ALLISON TANNER NP

Table of content: MRS. VIRGINIA ALLISON TANNER NP (NPI 1679921134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679921134 NPI number — MRS. VIRGINIA ALLISON TANNER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANNER
Provider First Name:
VIRGINIA
Provider Middle Name:
ALLISON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679921134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
458 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAYTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30525-4254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-960-9550
Provider Business Mailing Address Fax Number:
706-960-9551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2420 WESTGATE DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31707-2249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-903-4044
Provider Business Practice Location Address Fax Number:
229-903-4055
Provider Enumeration Date:
05/25/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SF0001X , with the licence number:  RN217872 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: RN217872 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: RN217872 . This is a "LICENSE NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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