Provider Demographics
NPI:1508384389
Name:TANNER, SAMMANTHA
Entity Type:Individual
Prefix:
First Name:SAMMANTHA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 E 5600 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6935
Mailing Address - Country:US
Mailing Address - Phone:801-528-2575
Mailing Address - Fax:
Practice Address - Street 1:3848 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84408-0001
Practice Address - Country:US
Practice Address - Phone:801-626-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer