Provider Demographics
NPI:1982831061
Name:BANNER, NICOLE (LMT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:BANNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 STONEY POINT CT
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20876-5565
Mailing Address - Country:US
Mailing Address - Phone:240-418-8655
Mailing Address - Fax:
Practice Address - Street 1:811 RUSSELL AVE STE B
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3524
Practice Address - Country:US
Practice Address - Phone:240-418-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM03967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist