Provider Demographics
NPI:1992888507
Name:TANNEN, MIRIAM BARBARA (NP)
Entity type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:BARBARA
Last Name:TANNEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 CAMBY RD
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-6209
Mailing Address - Country:US
Mailing Address - Phone:845-677-3935
Mailing Address - Fax:
Practice Address - Street 1:17 NOXON ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-4101
Practice Address - Country:US
Practice Address - Phone:845-471-1540
Practice Address - Fax:845-471-1644
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF360255-1363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0E0071Medicare ID - Type Unspecified