Provider Demographics
NPI:1275923252
Name:BANIISSA, HALIDA
Entity Type:Individual
Prefix:
First Name:HALIDA
Middle Name:
Last Name:BANIISSA
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 1:1876 W SERGEANT DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1876 W SERGEANT DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-4386
Practice Address - Country:US
Practice Address - Phone:801-637-1695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter