MEDICARE: MRS. VICKIE LYNN BANNISTER NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	4704145917	MI
2	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	4704145917	MI
3	363LW0102X	Women's Health Nurse Practitioner	4704145917	MI

General Provider Information

NPI Number	:	1497736342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICKIE LYNN BANNISTER NP

Provider Business Mailing Address
First Line	:	640 COURT ST
Second Line	:
City	:	WEST BRANCH
State	:	MI
Zip	:	48661-9390
Country	:	US
Telephone Number	:	989-345-8120
Fax Number	:	989-345-8129

Provider Business Practice Location Address
First Line	:	640 COURT ST
Second Line	:
City	:	WEST BRANCH
State	:	MI
Zip	:	48661-9390
Country	:	US
Telephone Number	:	989-345-8120
Fax Number	:	989-345-8129

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	07/21/2022

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