Provider Demographics
NPI:1356617435
Name:TANNER, LISETTE DAVIDSON (MD, MPH)
Entity type:Individual
Prefix:
First Name:LISETTE
Middle Name:DAVIDSON
Last Name:TANNER
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:LISETTE
Other - Middle Name:IRENE
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:6410 FANNIN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3000
Mailing Address - Country:US
Mailing Address - Phone:832-325-7288
Mailing Address - Fax:
Practice Address - Street 1:2000 10TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3703
Practice Address - Country:US
Practice Address - Phone:706-571-1285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86451207V00000X, 207VM0101X
CAA131471207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology