Basic Information
| Provider Information | |||||||||
| NPI: | 1447859970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANTHER | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2826 AMNICOLA HWY | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374063605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8338255246 | ||||||||
| FaxNumber: | 8778666152 | ||||||||
| Practice Location | |||||||||
| Address1: | 2826 AMNICOLA HWY | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374063605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8338255246 | ||||||||
| FaxNumber: | 8778666152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2020 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.