Healthcare Provider Details

I. General information

NPI: 1295935880
Provider Name (Legal Business Name): CAROL ANN BANKS R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W FOURTH STREET SUITE 100-A
MISHAWAKA IN
46544-1948
US

IV. Provider business mailing address

PO BOX 6489
SOUTH BEND IN
46660-6489
US

V. Phone/Fax

Practice location:
  • Phone: 574-252-0309
  • Fax: 574-472-3694
Mailing address:
  • Phone: 574-472-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number28120528A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: