Healthcare Provider Details

I. General information

NPI: 1104737980
Provider Name (Legal Business Name): ALEXA YANNIN TANNER RD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 S 500 W
PROVO UT
84601-4242
US

IV. Provider business mailing address

149 S 500 W
PROVO UT
84601-4242
US

V. Phone/Fax

Practice location:
  • Phone: 208-949-5685
  • Fax:
Mailing address:
  • Phone: 208-949-5685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: