Provider Demographics
NPI:1598482580
Name:O'BANNER, TYRONE
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:O'BANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 THEROUX DR APT 15F
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-3249
Mailing Address - Country:US
Mailing Address - Phone:413-218-4888
Mailing Address - Fax:
Practice Address - Street 1:137 THEROUX DR APT 15F
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-3249
Practice Address - Country:US
Practice Address - Phone:413-218-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2345699163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health