Provider Demographics
NPI:1114356656
Name:BANELLIS, ANN MARIE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:ANN MARIE
Middle Name:
Last Name:BANELLIS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:42 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-1916
Practice Address - Country:US
Practice Address - Phone:570-654-0880
Practice Address - Fax:570-655-9857
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASPO13117363LF0000X
PASP013117363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily