Healthcare Provider Details

I. General information

NPI: 1831176262
Provider Name (Legal Business Name): KERRY A FAY-BANNISTER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 CENTRAL AVENUE WENTWORTH DOUGLAS HOSPITAL
DOVER NH
03820
US

IV. Provider business mailing address

3998 FAIR RIDGE DR SUITE 300
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 603-749-7246
  • Fax: 603-749-2453
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number042782
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: