Healthcare Provider Details

I. General information

NPI: 1417228727
Provider Name (Legal Business Name): DIANA BANNISTER ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 GASTON AVE STE 100W
DALLAS TX
75214-6273
US

IV. Provider business mailing address

6301 GASTON AVE STE 100W
DALLAS TX
75214-6273
US

V. Phone/Fax

Practice location:
  • Phone: 214-827-3610
  • Fax: 214-821-4017
Mailing address:
  • Phone: 214-827-3610
  • Fax: 214-821-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number670576
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: