Healthcare Provider Details

I. General information

NPI: 1669302238
Provider Name (Legal Business Name): FELICIA BANAHENE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAAME BANAHENE

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22365 BARTON RD STE 302
GRAND TERRACE CA
92313-5078
US

IV. Provider business mailing address

16408 VALENCIA AVE UNIT 715
FONTANA CA
92335-7854
US

V. Phone/Fax

Practice location:
  • Phone: 909-386-2858
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: