Basic Information
| Provider Information | |||||||||
| NPI: | 1083011308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30180 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352565177 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2380 W HORIZON RIDGE PKWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890525078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028234255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2014 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7836957-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.