Provider Demographics
NPI:1962065219
Name:BANNING, KAITLYN R
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:R
Last Name:BANNING
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 1:1005 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1601
Mailing Address - Country:US
Mailing Address - Phone:928-776-8428
Mailing Address - Fax:833-449-5321
Practice Address - Street 1:1005 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1601
Practice Address - Country:US
Practice Address - Phone:928-776-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101027374207V00000X
AZ011238207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology