Provider Demographics
NPI:1417782699
Name:BANMAN, JAMIESON MICHELLE
Entity type:Individual
Prefix:
First Name:JAMIESON
Middle Name:MICHELLE
Last Name:BANMAN
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 1:911 W KAREN DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1441
Mailing Address - Country:US
Mailing Address - Phone:217-875-4103
Mailing Address - Fax:
Practice Address - Street 1:3133 PINEHURST DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-9145
Practice Address - Country:US
Practice Address - Phone:217-520-7145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.342804163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse