Provider Demographics
NPI:1679821417
Name:TANNER, MARSHA ANN (MT(AMT))
Entity Type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:ANN
Last Name:TANNER
Suffix:
Gender:F
Credentials:MT(AMT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 SCR 60
Mailing Address - Street 2:
Mailing Address - City:MIZE
Mailing Address - State:MS
Mailing Address - Zip Code:39116-5350
Mailing Address - Country:US
Mailing Address - Phone:601-678-7784
Mailing Address - Fax:
Practice Address - Street 1:452 SCR 60
Practice Address - Street 2:
Practice Address - City:MIZE
Practice Address - State:MS
Practice Address - Zip Code:39116-5350
Practice Address - Country:US
Practice Address - Phone:601-678-7784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-28
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACLP.201475-GEN246RM2200X
211278291U00000X
MLT 43092291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory