Provider Demographics
NPI:1053475723
Name:BANNISTER, KATIE (DPT)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 INMAN MEWS DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2499
Mailing Address - Country:US
Mailing Address - Phone:678-478-9858
Mailing Address - Fax:
Practice Address - Street 1:3615 BRASELTON HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5906
Practice Address - Country:US
Practice Address - Phone:770-904-6009
Practice Address - Fax:770-904-2357
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist