MEDICARE: DR. TYRA TANNER DNP, RD, ANP, CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	2010029866	MO
2	163W00000X	Registered Nurse	0001206597	VA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024172296	VA
4	363L00000X	Nurse Practitioner	0024172296	VA
5	364SA2200X	Adult Health Clinical Nurse Specialist	0015000947	VA
6	363LA2200X	Adult Health Nurse Practitioner	0024172296	VA

General Provider Information

NPI Number	:	1326340928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYRA TANNER DNP, RD, ANP, CNS

Provider Business Mailing Address
First Line	:	PO BOX 2947
Second Line	:
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-9118
Country	:	US
Telephone Number	:	804-616-4378
Fax Number	:	804-616-4378

Provider Business Practice Location Address
First Line	:	9401 COURTHOUSE RD
Second Line	:	STE 202
City	:	CHESTERFIELD
State	:	VA
Zip	:	23832-6687
Country	:	US
Telephone Number	:	804-616-4378
Fax Number	:	804-616-4378

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2010
Last Update Date	:	04/03/2025

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