Provider Demographics
NPI:1417738717
Name:TANNER, DONALD EDWIN (FNP-C)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:EDWIN
Last Name:TANNER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 NE BANNER DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-6715
Mailing Address - Country:US
Mailing Address - Phone:816-207-9099
Mailing Address - Fax:
Practice Address - Street 1:1120 NE BANNER DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6715
Practice Address - Country:US
Practice Address - Phone:816-207-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023041401363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily