Provider Demographics
NPI:1326726571
Name:TANNER, LEIGH ELLEN (MED)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ELLEN
Last Name:TANNER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-1558
Mailing Address - Country:US
Mailing Address - Phone:678-227-1664
Mailing Address - Fax:
Practice Address - Street 1:604 WASHINGTON ST NW STE B2
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-8545
Practice Address - Country:US
Practice Address - Phone:770-534-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005281235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty