Provider Demographics
NPI:1275877268
Name:BANISTER, MEKENZE L (LPN)
Entity Type:Individual
Prefix:
First Name:MEKENZE
Middle Name:L
Last Name:BANISTER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1142
Mailing Address - Country:US
Mailing Address - Phone:419-388-7528
Mailing Address - Fax:
Practice Address - Street 1:224 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1142
Practice Address - Country:US
Practice Address - Phone:419-388-7528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH146314164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH146314OtherOHIO BOARD OF NURSING