Healthcare Provider Details

I. General information

NPI: 1477974095
Provider Name (Legal Business Name): HENRIETTA BANNERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2013
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 UNIVERSITY PLZ
HACKENSACK NJ
07601-6202
US

IV. Provider business mailing address

274 MADISON AVE RM 1501
NEW YORK NY
10016-0701
US

V. Phone/Fax

Practice location:
  • Phone: 212-203-1773
  • Fax: 646-665-4427
Mailing address:
  • Phone: 212-203-1773
  • Fax: 646-665-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number678130
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR20490500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405453
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ14928000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: