Provider Demographics
NPI:1972113454
Name:TANNER, DONNA JEAN
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
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 1:7401 LITTLE KANAWHA PKWY
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26141-7527
Mailing Address - Country:US
Mailing Address - Phone:304-275-0153
Mailing Address - Fax:
Practice Address - Street 1:7401 LITTLE KANAWHA PKWY
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:WV
Practice Address - Zip Code:26141-7527
Practice Address - Country:US
Practice Address - Phone:304-275-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant