Provider Demographics
NPI:1588838379
Name:TANNER, MELISSA LEIGH (RN)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:LEIGH
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 1:209 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-2614
Mailing Address - Country:US
Mailing Address - Phone:719-539-4510
Mailing Address - Fax:719-539-7197
Practice Address - Street 1:209 E 3RD ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2614
Practice Address - Country:US
Practice Address - Phone:719-539-4510
Practice Address - Fax:719-539-7197
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO108735163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04419099Medicaid
CO04419099Medicaid