Provider Demographics
NPI:1790155315
Name:O'BANNON, RINEQUA
Entity Type:Individual
Prefix:MRS
First Name:RINEQUA
Middle Name:
Last Name:O'BANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5051
Mailing Address - Country:US
Mailing Address - Phone:804-350-4286
Mailing Address - Fax:
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-350-4286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-25
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172158363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care