Healthcare Provider Details

I. General information

NPI: 1790105872
Provider Name (Legal Business Name): SHANNON RENEE BANKS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3803 ROBERT PORCHER WAY
GREENSBORO NC
27410-2191
US

IV. Provider business mailing address

2100 STANTONSBURG RD
GREENVILLE NC
27834-2818
US

V. Phone/Fax

Practice location:
  • Phone: 336-286-3442
  • Fax:
Mailing address:
  • Phone: 252-744-4611
  • Fax: 252-744-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2017-02185
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: