Provider Demographics
NPI:1154673150
Name:ETCHI-BANYI, MARDI GRAS NANYONGO
Entity Type:Individual
Prefix:DR
First Name:MARDI GRAS
Middle Name:NANYONGO
Last Name:ETCHI-BANYI
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 1:9766 ROSEHILL RD APT I51
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-2221
Mailing Address - Country:US
Mailing Address - Phone:301-377-6096
Mailing Address - Fax:269-473-2566
Practice Address - Street 1:612 SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1603
Practice Address - Country:US
Practice Address - Phone:301-377-6096
Practice Address - Fax:269-473-2566
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302047702183500000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No374U00000XNursing Service Related ProvidersHome Health Aide