Provider Demographics
NPI:1497736342
Name:BANNISTER, VICKIE LYNN (NP)
Entity Type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:LYNN
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 COURT ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-9390
Mailing Address - Country:US
Mailing Address - Phone:989-345-8120
Mailing Address - Fax:989-345-8129
Practice Address - Street 1:640 COURT ST
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9390
Practice Address - Country:US
Practice Address - Phone:989-345-8120
Practice Address - Fax:989-345-8129
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704145917363L00000X, 363LX0001X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology