Provider Demographics
NPI:1033825419
Name:BANNISTER, LISA ANNE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-2231
Mailing Address - Country:US
Mailing Address - Phone:219-746-0764
Mailing Address - Fax:
Practice Address - Street 1:2400 GLENWOOD AVE STE 210
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5498
Practice Address - Country:US
Practice Address - Phone:630-473-8737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026405363LW0102X
IL041.360286163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse