Provider Demographics
NPI:1417228727
Name:BANNISTER, DIANA (ACNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 GASTON AVE STE 100W
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-6273
Mailing Address - Country:US
Mailing Address - Phone:214-827-3610
Mailing Address - Fax:214-821-4017
Practice Address - Street 1:6301 GASTON AVE STE 100W
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-6273
Practice Address - Country:US
Practice Address - Phone:214-827-3610
Practice Address - Fax:214-821-4017
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX670576363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care