Provider Demographics
NPI:1174229579
Name:TANNER, LAKEN RENEE (MSPAP, PA-C)
Entity type:Individual
Prefix:
First Name:LAKEN
Middle Name:RENEE
Last Name:TANNER
Suffix:
Gender:F
Credentials:MSPAP, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 RUFUS RD
Mailing Address - Street 2:
Mailing Address - City:WILLACOOCHEE
Mailing Address - State:GA
Mailing Address - Zip Code:31650-5400
Mailing Address - Country:US
Mailing Address - Phone:912-327-0659
Mailing Address - Fax:
Practice Address - Street 1:1900 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6357
Practice Address - Country:US
Practice Address - Phone:912-283-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11382363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant