Provider Demographics
NPI:1548042518
Name:TANNER, MILDRED MAXINE
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:MAXINE
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 1:532 WYOMING ST APT B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-2032
Mailing Address - Country:US
Mailing Address - Phone:304-644-7743
Mailing Address - Fax:
Practice Address - Street 1:532 WYOMING ST APT B
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-2032
Practice Address - Country:US
Practice Address - Phone:304-644-7743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant