Healthcare Provider Details

I. General information

NPI: 1679821417
Provider Name (Legal Business Name): MARSHA ANN TANNER MT(AMT)
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 SCR 60
MIZE MS
39116-5350
US

IV. Provider business mailing address

452 SCR 60
MIZE MS
39116-5350
US

V. Phone/Fax

Practice location:
  • Phone: 601-678-7784
  • Fax:
Mailing address:
  • Phone: 601-678-7784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License NumberCLP.201475-GEN
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number211278
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberMLT 43092
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: