Provider Demographics
NPI:1174614556
Name:BANNON BOISVERT, KAREN MARIE (DC)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:BANNON BOISVERT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MARIE
Other - Last Name:BANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:124 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-3826
Mailing Address - Country:US
Mailing Address - Phone:603-781-4774
Mailing Address - Fax:
Practice Address - Street 1:600 STATE ST
Practice Address - Street 2:SUITE 5
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4370
Practice Address - Country:US
Practice Address - Phone:603-430-7744
Practice Address - Fax:603-436-6729
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH163-0494111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0506836YONH01OtherANTHEM BCBS
NH424750OtherCIGNA HEALTHCARE
NH424750OtherHEALTHSOURCE
NH471703OtherHARVARD PILGRIM
NH1847758OtherFIRST HEALTH
NH0506836YONH01OtherANTHEM BCBS
NH1847758OtherFIRST HEALTH