Basic Information
| Provider Information | |||||||||
| NPI: | 1942238019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANNER | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 WILLIAM HOWARD TAFT RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133519900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1955 DIXIE HWY STE N | ||||||||
| Address2: | |||||||||
| City: | FT WRIGHT | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410112792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593416255 | ||||||||
| FaxNumber: | 8595471197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | NP07116 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LF0000X | 3009149 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2592207 | 05 | OH | MEDICAID |