Healthcare Provider Details

I. General information

NPI: 1043849391
Provider Name (Legal Business Name): KRISANDRA BANET
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W KENYON RD STE B
URBANA IL
61801-1006
US

IV. Provider business mailing address

2857 CHARLESTOWN RD STE 100
NEW ALBANY IN
47150-1998
US

V. Phone/Fax

Practice location:
  • Phone: 217-729-7657
  • Fax:
Mailing address:
  • Phone: 812-944-7500
  • Fax: 812-944-6424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003208A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: