Provider Demographics
NPI:1346905874
Name:TANNER, AMANDA LEIGH (CNM)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:TANNER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 PATRICK RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-1177
Mailing Address - Country:US
Mailing Address - Phone:307-369-3608
Mailing Address - Fax:
Practice Address - Street 1:7356 STOCKMAN ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-6006
Practice Address - Country:US
Practice Address - Phone:307-632-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-31
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCS04520363L00000X
COC-APN.0003391-C-CNM363LX0001X
COC-RXN.0001685-C-CNM363LX0001X
WY48730363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner