Basic Information
Provider Information | |||||||||
NPI: | 1407035744 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BANVILLE | ||||||||
FirstName: | JEAN | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HALL, CUNNINGHAM | ||||||||
OtherFirstName: | JEAN | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 401 CYPRESS ST | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 031033628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036684111 | ||||||||
FaxNumber: | 6036287757 | ||||||||
Practice Location | |||||||||
Address1: | 1228 ELM ST | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | NH | ||||||||
PostalCode: | 031011349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6036684111 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2007 | ||||||||
LastUpdateDate: | 11/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 021072-21 | NH | N |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 051072-23 | NH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.