Provider Demographics
NPI:1629307533
Name:BANNING, CLINTON DALE (FNP)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:DALE
Last Name:BANNING
Suffix:
Gender:M
Credentials:FNP
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 338
Mailing Address - Street 2:133 WINNIE WALKER LANE
Mailing Address - City:GLENDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97442-0338
Mailing Address - Country:US
Mailing Address - Phone:541-832-2335
Mailing Address - Fax:
Practice Address - Street 1:500 SW RAMSEY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527
Practice Address - Country:US
Practice Address - Phone:541-472-7069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2001141562RN163W00000X
OR201050003NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse