Provider Demographics
NPI:1376732974
Name:TANNER, LISA DIANE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANE
Last Name:TANNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 IDLEWILDE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-2475
Mailing Address - Country:US
Mailing Address - Phone:740-788-9157
Mailing Address - Fax:
Practice Address - Street 1:988 IDLEWILDE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-2475
Practice Address - Country:US
Practice Address - Phone:740-788-9157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN257113163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse