Provider Demographics
NPI:1598149775
Name:BANNER, KELLI (FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BANNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 LOGAN STREET
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-2856
Mailing Address - Country:US
Mailing Address - Phone:828-559-1044
Mailing Address - Fax:828-559-2039
Practice Address - Street 1:61 LOGAN STREET
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-2856
Practice Address - Country:US
Practice Address - Phone:828-559-1044
Practice Address - Fax:828-559-2039
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC804923163W00000X
NC5009995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831789817OtherGROUP NPI