Provider Demographics
NPI:1225061468
Name:BANISTER, CAROL ANN (RD)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:BANISTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 WOODHILL RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-2930
Mailing Address - Country:US
Mailing Address - Phone:405-349-0063
Mailing Address - Fax:
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:SUITE 701
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-755-7561
Practice Address - Fax:405-755-7615
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK251133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered