Healthcare Provider Details

I. General information

NPI: 1679921134
Provider Name (Legal Business Name): VIRGINIA ALLISON TANNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2016
Last Update Date: 06/05/2020
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 WESTGATE DR SUITE 102
ALBANY GA
31707-2249
US

IV. Provider business mailing address

458 N MAIN ST
CLAYTON GA
30525-4254
US

V. Phone/Fax

Practice location:
  • Phone: 229-903-4044
  • Fax: 229-903-4055
Mailing address:
  • Phone: 706-960-9550
  • Fax: 706-960-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberRN217872
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN217872
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: