MEDICARE: KELLY C BANONIS 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	363LF0000X	Family Nurse Practitioner	245540	AZ
2	363LF0000X	Family Nurse Practitioner	1112632	TX

General Provider Information

NPI Number	:	1790395531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY C BANONIS NP

Provider Business Mailing Address
First Line	:	605 E SAN ANTONIO ST STE 510E
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77901-6011
Country	:	US
Telephone Number	:	361-788-6003
Fax Number	:	361-788-6074

Provider Business Practice Location Address
First Line	:	605 E SAN ANTONIO ST STE 510E
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77901-6011
Country	:	US
Telephone Number	:	361-576-9342
Fax Number	:

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

Provider Enumeration Date	:	08/06/2020
Last Update Date	:	08/01/2024

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Directions to “ KELLY C BANONIS NP” Practice Location

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