Provider Demographics
NPI:1811960750
Name:TANNATT, BETH (DPT)
Entity type:Individual
Prefix:MRS
First Name:BETH
Middle Name:
Last Name:TANNATT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 STILLMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1827
Mailing Address - Country:US
Mailing Address - Phone:860-536-1001
Mailing Address - Fax:
Practice Address - Street 1:2440 GOLD STAR HWY
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1180
Practice Address - Country:US
Practice Address - Phone:860-536-1001
Practice Address - Fax:860-536-1527
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI01975174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007058009Medicare ID - Type UnspecifiedPROVIDER ID NUMBER