Provider Demographics
NPI:1558191668
Name:BANNERMAN, ALISSA MARIE
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:MARIE
Last Name:BANNERMAN
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 1:8530 SW 74TH ST UNIT 6B8530SW
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73169-1209
Mailing Address - Country:US
Mailing Address - Phone:405-496-9535
Mailing Address - Fax:
Practice Address - Street 1:6100 S WALKER AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-7026
Practice Address - Country:US
Practice Address - Phone:405-634-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty