Provider Demographics
NPI:1659010940
Name:TANNER, REAGAN
Entity Type:Individual
Prefix:
First Name:REAGAN
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:PO BOX 569
Mailing Address - Street 2:
Mailing Address - City:MOUNT NEBO
Mailing Address - State:WV
Mailing Address - Zip Code:26679-0569
Mailing Address - Country:US
Mailing Address - Phone:304-883-2334
Mailing Address - Fax:
Practice Address - Street 1:785 SUMMERSVILLE LAKE RD
Practice Address - Street 2:
Practice Address - City:MOUNT NEBO
Practice Address - State:WV
Practice Address - Zip Code:26679-9203
Practice Address - Country:US
Practice Address - Phone:304-883-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant