MEDICARE: MRS. CAROL B TANNER CRNA

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	367500000X	Certified Registered Nurse Anesthetist	2043774406	UT

General Provider Information

NPI Number	:	1417019456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL B TANNER CRNA

Provider Business Mailing Address
First Line	:	45 S MOUNTAIN RD
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-2313
Country	:	US
Telephone Number	:	801-726-1340
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 S MOUNTAIN RD
Second Line	:
City	:	FRUIT HEIGHTS
State	:	UT
Zip	:	84037-2313
Country	:	US
Telephone Number	:	801-726-1340
Fax Number	:

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

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	12/16/2021

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