MEDICARE: NICHOLE LAUREN BANFIELD O.D.

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	152W00000X	Optometrist	OPT-002730	AZ

General Provider Information

NPI Number	:	1609560432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE LAUREN BANFIELD O.D.

Provider Business Mailing Address
First Line	:	2008 N 50TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85035-3925
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4101 N 56TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-1267
Country	:	US
Telephone Number	:	414-447-9403
Fax Number	:

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

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/07/2024

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