Provider Demographics
NPI:1487208286
Name:BANTA, LISA YVONNE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:YVONNE
Last Name:BANTA
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 1:307 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1628
Mailing Address - Country:US
Mailing Address - Phone:859-391-8768
Mailing Address - Fax:
Practice Address - Street 1:830 EZZARD CHARLES DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-2525
Practice Address - Country:US
Practice Address - Phone:513-381-6672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH084499164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse