Provider Demographics
NPI:1962787663
Name:O'BANNER, LATIA IRENE (RN)
Entity type:Individual
Prefix:
First Name:LATIA
Middle Name:IRENE
Last Name:O'BANNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4372 BREEDERS CUP CIR
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-4049
Mailing Address - Country:US
Mailing Address - Phone:443-790-0362
Mailing Address - Fax:
Practice Address - Street 1:4372 BREEDERS CUP CIR
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4049
Practice Address - Country:US
Practice Address - Phone:443-790-0362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR162086163W00000X
PARN626135163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse