Provider Demographics
NPI:1750985511
Name:TAVENNER, ANGELA MARIE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:TAVENNER
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 1:4836 VICTORY CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-8831
Mailing Address - Country:US
Mailing Address - Phone:614-600-7654
Mailing Address - Fax:
Practice Address - Street 1:4836 VICTORY CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-8831
Practice Address - Country:US
Practice Address - Phone:614-600-7654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant