Provider Demographics
NPI:1679921134
Name:TANNER, VIRGINIA ALLISON (NP)
Entity type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:ALLISON
Last Name:TANNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-4254
Mailing Address - Country:US
Mailing Address - Phone:706-960-9550
Mailing Address - Fax:706-960-9551
Practice Address - Street 1:2420 WESTGATE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2249
Practice Address - Country:US
Practice Address - Phone:229-903-4044
Practice Address - Fax:229-903-4055
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217872364SF0001X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN217872OtherLICENSE NUMBER