Provider Demographics
NPI:1326340928
Name:TANNER, TYRA (DNP, RD, ANP, CNS)
Entity Type:Individual
Prefix:DR
First Name:TYRA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:DNP, RD, ANP, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2947
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-9118
Mailing Address - Country:US
Mailing Address - Phone:804-616-4378
Mailing Address - Fax:804-616-4378
Practice Address - Street 1:9401 COURTHOUSE RD
Practice Address - Street 2:STE 202
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832-6687
Practice Address - Country:US
Practice Address - Phone:804-616-4378
Practice Address - Fax:804-616-4378
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010029866133V00000X
VA0001206597163W00000X
VA0015000947364SA2200X
VA0024172296363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ406080281Medicare PIN