=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679921134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIRGINIA ALLISON TANNER NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2016
-----------------------------------------------------
Last Update Date | 06/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2420 WESTGATE DR SUITE 102
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31707-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-903-4044
-----------------------------------------------------
Fax | 229-903-4055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 458 N MAIN ST
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30525-4254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-960-9550
-----------------------------------------------------
Fax | 706-960-9551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SF0001X
-----------------------------------------------------
Taxonomy Name | Family Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | RN217872
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN217872
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------