Provider Demographics
NPI:1477974095
Name:BANNERMAN, HENRIETTA
Entity Type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:
Last Name:BANNERMAN
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:PO BOX 41148
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-7148
Mailing Address - Country:US
Mailing Address - Phone:347-575-0327
Mailing Address - Fax:
Practice Address - Street 1:339 JEFFRIES ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3213
Practice Address - Country:US
Practice Address - Phone:347-575-0327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY678130163W00000X
NJ26NR20490500163W00000X
NJ26NJ14928000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse