Provider Demographics
NPI:1720796543
Name:TANNER, LIZA MARIE
Entity Type:Individual
Prefix:
First Name:LIZA
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 1:48189 HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920-9604
Mailing Address - Country:US
Mailing Address - Phone:330-843-0652
Mailing Address - Fax:
Practice Address - Street 1:48189 HILL RD
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920-9604
Practice Address - Country:US
Practice Address - Phone:330-843-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1821206228Medicaid
WV1356607394Medicaid