Provider Demographics
NPI:1932537511
Name:TANNER, SUSAN (APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11499 BARTLETT AVE
Mailing Address - Street 2:
Mailing Address - City:ADELANTO
Mailing Address - State:CA
Mailing Address - Zip Code:92301-1902
Mailing Address - Country:US
Mailing Address - Phone:760-444-4258
Mailing Address - Fax:
Practice Address - Street 1:11499 BARTLETT AVE
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-1902
Practice Address - Country:US
Practice Address - Phone:760-444-4258
Practice Address - Fax:760-530-9977
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN78518163W00000X
GARN199226363LF0000X
CA23395363LF0000X
SC20147363LF0000X, 363LP0808X
NVAPRN001698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1932537511Medicaid
NVV111259Medicare PIN