Basic Information
| Provider Information | |||||||||
| NPI: | 1497736342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANNISTER | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 COURT ST | ||||||||
| Address2: | |||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486619390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893458120 | ||||||||
| FaxNumber: | 9893458129 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 COURT ST | ||||||||
| Address2: | |||||||||
| City: | WEST BRANCH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486619390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893458120 | ||||||||
| FaxNumber: | 9893458129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704145917 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LX0001X | 4704145917 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 363LW0102X | 4704145917 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.