Provider Demographics
NPI:1609488873
Name:TANNER, LARA FLINN
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:FLINN
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 1:3579 US HIGHWAY 220 N
Mailing Address - Street 2:
Mailing Address - City:MOOREFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:26836-8642
Mailing Address - Country:US
Mailing Address - Phone:304-668-4755
Mailing Address - Fax:
Practice Address - Street 1:701 LEE ST
Practice Address - Street 2:
Practice Address - City:MOOREFIELD
Practice Address - State:WV
Practice Address - Zip Code:26836-1079
Practice Address - Country:US
Practice Address - Phone:304-538-7541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant