Provider Demographics
NPI:1760243661
Name:O'BANNON, ANTILISHIA (CRANIAL PROSTHESIS)
Entity Type:Individual
Prefix:
First Name:ANTILISHIA
Middle Name:
Last Name:O'BANNON
Suffix:
Gender:F
Credentials:CRANIAL PROSTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25140 LAHSER RD STE 212
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-6200
Mailing Address - Country:US
Mailing Address - Phone:313-452-2662
Mailing Address - Fax:
Practice Address - Street 1:25140 LAHSER RD STE 212
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6200
Practice Address - Country:US
Practice Address - Phone:313-452-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier