Healthcare Provider Details

I. General information

NPI: 1497736342
Provider Name (Legal Business Name): VICKIE LYNN BANNISTER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 COURT ST
WEST BRANCH MI
48661-9390
US

IV. Provider business mailing address

640 COURT ST
WEST BRANCH MI
48661-9390
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-8120
  • Fax: 989-345-8129
Mailing address:
  • Phone: 989-345-8120
  • Fax: 989-345-8129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704145917
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number4704145917
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704145917
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: