Individual
MANDI LOU TANNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
APRN
Contact information
Practice address
2512 W 2725 N, FARR WEST, UT 84404-9469
(801) 309-6285
(801) 820-0401
Mailing address
2512 W 2725 N, FARR WEST, UT 84404-9469
(801) 309-6285
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
4807317-4405
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000055266
MEDICARE PIN
UT
01
—
260022408
RAILROAD MEDICARE
UT
01
—
4807317-4405
APRN LICENSE
UT
01
—
4807317-8900
CONTROLLED SUBSTANCE LICENSE
UT
05
—
8760003008007
—
UT
Enumeration date
09/09/2021
Last updated
04/15/2024
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