Provider Demographics
NPI:1295080521
Name:BANYARD, KEMBA (NP)
Entity type:Individual
Prefix:
First Name:KEMBA
Middle Name:
Last Name:BANYARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KEMBA
Other - Middle Name:
Other - Last Name:MCCAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC DNP
Mailing Address - Street 1:2468 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1413
Mailing Address - Country:US
Mailing Address - Phone:262-977-7771
Mailing Address - Fax:262-435-4929
Practice Address - Street 1:2468 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-1413
Practice Address - Country:US
Practice Address - Phone:414-204-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4887363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI019940725Medicare PIN
WI462364946Medicare PIN