Provider Demographics
NPI:1275738593
Name:TANNER, MICHELLE CORYELL (PT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CORYELL
Last Name:TANNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:CORYELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:45 ENTERPRISE PATH
Practice Address - Street 2:SUITE 101
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2691
Practice Address - Country:US
Practice Address - Phone:770-439-4045
Practice Address - Fax:770-439-4085
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00454332OtherRAILROAD PIN
GAGRP4895Medicare Oscar/Certification
GAP00454332OtherRAILROAD PIN
GA65BBFFPMedicare PIN