Provider Demographics
NPI:1922034271
Name:BANNISTER, LEA MARY (MD)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:MARY
Last Name:BANNISTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 N BROTHER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-2760
Mailing Address - Country:US
Mailing Address - Phone:901-255-5221
Mailing Address - Fax:901-373-4511
Practice Address - Street 1:6215 HUMPHREYS BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2367
Practice Address - Country:US
Practice Address - Phone:901-767-8448
Practice Address - Fax:901-684-6260
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD024990207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3148944OtherBCBS
TN3148944OtherBCBS
TN160052339OtherMEDICARE RR
TNF73367Medicare UPIN