Provider Demographics
NPI:1891043725
Name:BANNER, JUDY (APRN)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:BANNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 REDBUD HOLW
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-9714
Mailing Address - Country:US
Mailing Address - Phone:405-562-0213
Mailing Address - Fax:
Practice Address - Street 1:3330 NW 56TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4479
Practice Address - Country:US
Practice Address - Phone:405-945-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR62457363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics