Healthcare Provider Details

I. General information

NPI: 1598149775
Provider Name (Legal Business Name): KELLI BANNER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 04/16/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 LOGAN STREET
MARION NC
28752-2856
US

IV. Provider business mailing address

61 LOGAN STREET
MARION NC
28752-2856
US

V. Phone/Fax

Practice location:
  • Phone: 828-559-1044
  • Fax: 828-559-2039
Mailing address:
  • Phone: 828-559-1044
  • Fax: 828-559-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number804923
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5009995
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: