Provider Demographics
NPI:1043849391
Name:BANET, KRISANDRA
Entity Type:Individual
Prefix:
First Name:KRISANDRA
Middle Name:
Last Name:BANET
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 1:2857 CHARLESTOWN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-1998
Mailing Address - Country:US
Mailing Address - Phone:812-944-7500
Mailing Address - Fax:812-944-6424
Practice Address - Street 1:1111 W KENYON RD STE B
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-1006
Practice Address - Country:US
Practice Address - Phone:217-729-7657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN10003208A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program