Provider Demographics
NPI:1154076123
Name:TANNER, CASEY (PNP)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5461 MERIDIAN MARK RD STE 570
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-2807
Mailing Address - Country:US
Mailing Address - Phone:404-785-6895
Mailing Address - Fax:404-785-6896
Practice Address - Street 1:5461 MERIDIAN MARK RD STE 570
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-2807
Practice Address - Country:US
Practice Address - Phone:404-785-6895
Practice Address - Fax:404-785-6896
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN220734363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics