Provider Demographics
NPI:1639832025
Name:BANNON, KATHY KHRISTINA (NP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:KHRISTINA
Last Name:BANNON
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 1:2723 S 7TH ST STE O
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3562
Mailing Address - Country:US
Mailing Address - Phone:812-232-1418
Mailing Address - Fax:812-232-2642
Practice Address - Street 1:2723 S 7TH ST STE O
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-3562
Practice Address - Country:US
Practice Address - Phone:812-232-1418
Practice Address - Fax:812-232-2642
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28112203A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily