Provider Demographics
NPI:1851839310
Name:TANNER, GABRIELLE MARIE
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:MARIE
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 1:30 HAGEN DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2658
Mailing Address - Country:US
Mailing Address - Phone:585-922-0150
Mailing Address - Fax:
Practice Address - Street 1:30 HAGEN DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2658
Practice Address - Country:US
Practice Address - Phone:585-922-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-05
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341321363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily