Provider Demographics
NPI:1811964034
Name:BANNON, KATHLEEN MARIE (APRN)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BANNON
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 1:54 SAINT MORITZ CIR
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-2210
Mailing Address - Country:US
Mailing Address - Phone:860-684-4396
Mailing Address - Fax:
Practice Address - Street 1:31 UNION ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:CT
Practice Address - Zip Code:06066-3126
Practice Address - Country:US
Practice Address - Phone:860-872-5170
Practice Address - Fax:860-872-5206
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002093363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health