MEDICARE: DR. VICKI LYNN TANNER PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	78-26P	AR

General Provider Information

NPI Number	:	1407836661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICKI LYNN TANNER PH.D.

Provider Business Mailing Address
First Line	:	2024 ARKANSAS VALLEY DR
Second Line	:	SUITE 308
City	:	LITTLE ROCK
State	:	AR
Zip	:	72212-4166
Country	:	US
Telephone Number	:	501-223-9878
Fax Number	:	501-868-7475

Provider Business Practice Location Address
First Line	:	2024 ARKANSAS VALLEY DR
Second Line	:	SUITE 308
City	:	LITTLE ROCK
State	:	AR
Zip	:	72212-4166
Country	:	US
Telephone Number	:	501-223-9878
Fax Number	:	501-868-7475

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2006
Last Update Date	:	07/08/2007

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