Provider Demographics
NPI:1629295225
Name:TANNER, BECKY LYNN (NMD)
Entity Type:Individual
Prefix:DR
First Name:BECKY
Middle Name:LYNN
Last Name:TANNER
Suffix:
Gender:F
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 W COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80904-3809
Mailing Address - Country:US
Mailing Address - Phone:719-964-4732
Mailing Address - Fax:719-634-6469
Practice Address - Street 1:1721 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3809
Practice Address - Country:US
Practice Address - Phone:719-964-4732
Practice Address - Fax:719-634-6469
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ05-880261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care