Healthcare Provider Details

I. General information

NPI: 1003164963
Provider Name (Legal Business Name): MRS. DIANNE TABLAN BANAWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S SUNRISE WAY
PALM SPRINGS CA
92262-7663
US

IV. Provider business mailing address

425 S SUNRISE WAY
PALM SPRINGS CA
92262-7663
US

V. Phone/Fax

Practice location:
  • Phone: 760-327-4381
  • Fax: 760-327-4388
Mailing address:
  • Phone: 760-327-4381
  • Fax: 760-327-4388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number66722
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: