Healthcare Provider Details

I. General information

NPI: 1598372807
Provider Name (Legal Business Name): DAVID BRYAN TANIS DNP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42104 N VENTURE DR STE D106
ANTHEM AZ
85086-3836
US

IV. Provider business mailing address

6677 W THUNDERBIRD RD STE I164
GLENDALE AZ
85306-3762
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2100
  • Fax:
Mailing address:
  • Phone: 623-878-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number254061
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN209918
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: