Healthcare Provider Details

I. General information

NPI: 1407836661
Provider Name (Legal Business Name): VICKI LYNN TANNER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 ARKANSAS VALLEY DR SUITE 308
LITTLE ROCK AR
72212-4166
US

IV. Provider business mailing address

2024 ARKANSAS VALLEY DR SUITE 308
LITTLE ROCK AR
72212-4166
US

V. Phone/Fax

Practice location:
  • Phone: 501-223-9878
  • Fax: 501-868-7475
Mailing address:
  • Phone: 501-223-9878
  • Fax: 501-868-7475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number78-26P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: