Provider Demographics
NPI:1952707564
Name:BANSEE, JULISSA ANN
Entity type:Individual
Prefix:DR
First Name:JULISSA
Middle Name:ANN
Last Name:BANSEE
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 1:3285 CYPRESS LEGENDS CIR APT 927
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-5537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7950 DANI DR STE 200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-8012
Practice Address - Country:US
Practice Address - Phone:239-936-3969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL52560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist