Healthcare Provider Details

I. General information

NPI: 1497130801
Provider Name (Legal Business Name): ALEXA TANNER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26215 RIDGE RD
DAMASCUS MD
20872-1829
US

IV. Provider business mailing address

6455 S WIND CIR
COLUMBIA MD
21044-6016
US

V. Phone/Fax

Practice location:
  • Phone: 301-253-1100
  • Fax: 301-825-5163
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR206585
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: