Provider Demographics
NPI:1114579331
Name:TANNER, CALA BROOKE
Entity type:Individual
Prefix:
First Name:CALA
Middle Name:BROOKE
Last Name:TANNER
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 1:460 MALL BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4801
Mailing Address - Country:US
Mailing Address - Phone:912-644-5346
Mailing Address - Fax:912-644-3369
Practice Address - Street 1:125 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30453-4641
Practice Address - Country:US
Practice Address - Phone:912-644-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN249159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily