Provider Demographics
NPI:1164861654
Name:BANNER, DONNA J (RN, BSN)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:J
Last Name:BANNER
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 AUTUMN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4175
Mailing Address - Country:US
Mailing Address - Phone:262-354-0465
Mailing Address - Fax:
Practice Address - Street 1:961 AUTUMN RIDGE DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4175
Practice Address - Country:US
Practice Address - Phone:262-354-0465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI195520-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse