Provider Demographics
NPI:1144978347
Name:TANNER, MADISON GRACE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:GRACE
Last Name:TANNER
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 1:1910 E 1ST ST UNIT 123
Mailing Address - Street 2:
Mailing Address - City:GULF SHORES
Mailing Address - State:AL
Mailing Address - Zip Code:36542-6675
Mailing Address - Country:US
Mailing Address - Phone:912-816-0292
Mailing Address - Fax:
Practice Address - Street 1:1910 E 1ST ST UNIT 123
Practice Address - Street 2:
Practice Address - City:GULF SHORES
Practice Address - State:AL
Practice Address - Zip Code:36542-6675
Practice Address - Country:US
Practice Address - Phone:912-816-0292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program