MEDICARE: ALLISON ANNE BANNICK NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	4704230314	MI

General Provider Information

NPI Number	:	1821103441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLISON ANNE BANNICK NP

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE # MC845
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 MICHIGAN ST NE STE 3003
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2528
Country	:	US
Telephone Number	:	616-486-9830
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	03/06/2025

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