Provider Demographics
NPI:1992218895
Name:BANNER, KELLY NICHOLE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICHOLE
Last Name:BANNER
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 1:55 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:SABINA
Mailing Address - State:OH
Mailing Address - Zip Code:45169-1312
Mailing Address - Country:US
Mailing Address - Phone:937-971-1094
Mailing Address - Fax:
Practice Address - Street 1:42 N PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1757
Practice Address - Country:US
Practice Address - Phone:866-755-4258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator