Provider Demographics
NPI:1447289905
Name:TANNER, PHYLLIS A (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:A
Last Name:TANNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MISS
Other - First Name:PHYLLIS
Other - Middle Name:A
Other - Last Name:BAIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:1 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7430
Mailing Address - Country:US
Mailing Address - Phone:423-844-4157
Mailing Address - Fax:423-844-4149
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-4157
Practice Address - Fax:423-844-4149
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000001415235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist