Provider Demographics
NPI:1770512329
Name:BANNISTER, RENA M (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:RENA
Middle Name:M
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 GRAY RUN DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35824-1349
Mailing Address - Country:US
Mailing Address - Phone:256-533-4626
Mailing Address - Fax:256-533-4710
Practice Address - Street 1:2325 PANSY ST SW
Practice Address - Street 2:SUITE E
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3834
Practice Address - Country:US
Practice Address - Phone:256-533-4626
Practice Address - Fax:253-533-4710
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL 1 021431363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000079656Medicaid
AL000079656Medicaid
ALS56051Medicare UPIN