Provider Demographics
NPI:1487211827
Name:BANNERMAN, TEONDRA
Entity Type:Individual
Prefix:MISS
First Name:TEONDRA
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 312
Mailing Address - Street 2:
Mailing Address - City:ROSE HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28458-0312
Mailing Address - Country:US
Mailing Address - Phone:910-379-5707
Mailing Address - Fax:
Practice Address - Street 1:318 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:ROSE HILL
Practice Address - State:NC
Practice Address - Zip Code:28458
Practice Address - Country:US
Practice Address - Phone:910-447-2509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-26186101YA0400X
NC376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No376G00000XNursing Service Related ProvidersNursing Home Administrator