Provider Demographics
NPI:1639828437
Name:JAMES-TANNER, TRINA
Entity Type:Individual
Prefix:
First Name:TRINA
Middle Name:
Last Name:JAMES-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 1:150 E POND ST STE 5A
Mailing Address - Street 2:
Mailing Address - City:CENTURY
Mailing Address - State:FL
Mailing Address - Zip Code:32535-2859
Mailing Address - Country:US
Mailing Address - Phone:850-366-4067
Mailing Address - Fax:
Practice Address - Street 1:150 E POND ST STE 5A
Practice Address - Street 2:
Practice Address - City:CENTURY
Practice Address - State:FL
Practice Address - Zip Code:32535-2859
Practice Address - Country:US
Practice Address - Phone:850-366-4067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCA338510146N00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL873767982Medicaid