Provider Demographics
NPI:1477974095
Name:BANNERMAN, HENRIETTA
Entity type:Individual
Prefix:
First Name:HENRIETTA
Middle Name:
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 1:274 MADISON AVE RM 1501
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0701
Mailing Address - Country:US
Mailing Address - Phone:212-203-1773
Mailing Address - Fax:646-665-4427
Practice Address - Street 1:2 UNIVERSITY PLZ
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-6202
Practice Address - Country:US
Practice Address - Phone:212-203-1773
Practice Address - Fax:646-665-4427
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2025-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY678130163W00000X
NJ26NR20490500163W00000X
NY405453363LP0808X
NJ26NJ14928000363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse