Provider Demographics
NPI:1437519402
Name:BANNISTER, KENNETH G
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:BANNISTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 26TH AVE E
Mailing Address - Street 2:APT 101
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205
Mailing Address - Country:US
Mailing Address - Phone:941-962-7542
Mailing Address - Fax:
Practice Address - Street 1:302 26TH AVENUE EAST
Practice Address - Street 2:APT 101
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205
Practice Address - Country:US
Practice Address - Phone:941-962-7542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA71840225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist