Healthcare Provider Details

I. General information

NPI: 1154651610
Provider Name (Legal Business Name): CAITLYN TANNER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTER ST NE SUITE 301
ALBUQUERQUE NM
87102-2534
US

IV. Provider business mailing address

5400 GIBSON BLVD SE 2ND FLOOR / PHARMACY
ALBUQUERQUE NM
87108-4729
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7451
  • Fax:
Mailing address:
  • Phone: 505-262-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00007026
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: