Provider Demographics
NPI:1417019456
Name:TANNER, CAROL B (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:B
Last Name:TANNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 S MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:FRUIT HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84037-2313
Mailing Address - Country:US
Mailing Address - Phone:801-726-1340
Mailing Address - Fax:
Practice Address - Street 1:45 S MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:FRUIT HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84037-2313
Practice Address - Country:US
Practice Address - Phone:801-726-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2043774406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered