Healthcare Provider Details

I. General information

NPI: 1679059901
Provider Name (Legal Business Name): JEREE SHANTE BANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 LAVA TRL
FAYETTEVILLE NC
28311-1920
US

IV. Provider business mailing address

682 LAVA TRL
FAYETTEVILLE NC
28311-1920
US

V. Phone/Fax

Practice location:
  • Phone: 910-676-8158
  • Fax:
Mailing address:
  • Phone: 910-676-8158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: