Provider Demographics
NPI:1689961062
Name:TANNER, BERTHA ANN (RN)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:ANN
Last Name:TANNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HCR 6100 BOX 30
Mailing Address - Street 2:
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:928-656-5164
Practice Address - Street 1:JCT. HWY 160 & NAVAJO ROUTE 35 - RED MESA
Practice Address - Street 2:
Practice Address - City:TEEC NOS POS
Practice Address - State:AZ
Practice Address - Zip Code:86514
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:928-656-5164
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NML07936163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse