Provider Demographics
NPI:1821751157
Name:TANNER, MICHELLE RENEE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
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 793
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-0793
Mailing Address - Country:US
Mailing Address - Phone:325-704-1718
Mailing Address - Fax:
Practice Address - Street 1:23 HOSPITAL DR STE 102
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5270
Practice Address - Country:US
Practice Address - Phone:325-238-9337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty