Healthcare Provider Details

I. General information

NPI: 1609034453
Provider Name (Legal Business Name): MISTY NICOLE BANKNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTY BANKNELL HANEY PA-C

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N JEFFERSON ST NE
MILLEDGEVILLE GA
31061-3418
US

IV. Provider business mailing address

2400 BELLEVUE RD STE 21A
DUBLIN GA
31021-2890
US

V. Phone/Fax

Practice location:
  • Phone: 478-453-8484
  • Fax: 478-452-0987
Mailing address:
  • Phone: 478-275-7202
  • Fax: 478-274-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005333
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005333
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005333
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: