MEDICARE: MILLICENT TANNER R.D.,C.D.E.

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1467495242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MILLICENT TANNER R.D.,C.D.E.

Provider Business Mailing Address
First Line	:	340 16TH AVE N
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4819
Country	:	US
Telephone Number	:	904-247-1911
Fax Number	:	904-247-9736

Provider Business Practice Location Address
First Line	:	340 16TH AVE N
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-4819
Country	:	US
Telephone Number	:	904-247-1911
Fax Number	:	904-247-9736

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

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/08/2007

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