MEDICARE: JACKIE R TANNER ARNP

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	363L00000X	Nurse Practitioner	APRN9208911	FL

General Provider Information

NPI Number	:	1609229343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE R TANNER ARNP

Provider Business Mailing Address
First Line	:	638 HARRISON AVE STE 102
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-2662
Country	:	US
Telephone Number	:	850-558-4400
Fax Number	:

Provider Business Practice Location Address
First Line	:	638 HARRISON AVE STE 102
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32401-2662
Country	:	US
Telephone Number	:	850-558-4400
Fax Number	:

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

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	03/12/2024

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