MEDICARE: CANDACE RAELYNN BANKS M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	5035807	AZ

General Provider Information

NPI Number	:	1386162030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDACE RAELYNN BANKS M.A.

Provider Business Mailing Address
First Line	:	4114 N 28TH ST APT 3042
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-5943
Country	:	US
Telephone Number	:	504-453-4174
Fax Number	:

Provider Business Practice Location Address
First Line	:	8361 N 95TH AVE
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-7717
Country	:	US
Telephone Number	:	623-412-4825
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2017
Last Update Date	:	09/01/2017

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